Individual Contract Provider Application

Please complete the entire application and provide all required documentation. Incomplete Application Packets will not be processed. Mark N/A on questions that do not apply.

Job Applying For: Supported Home Living/Community Supports

• I. GENERAL INFORMATION
  Personal Information

  Last Name
  First Name
  MI
  
  Name of Business (if any)
  
  Home Phone Number
  Work Phone Number
  Cell Phone Number
  
  Email Address
  
  

  Home/Business Address

  Street Address
  City
  State
  AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY Zip Code
  

  Billing Address: (same as Home/Business Address)

  Street Address
  City
  State
  AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY Zip Code
  

  Contact Person Information

  Contact Person for the Contract
  Phone
  
  Contact Email Address
  

  Additional Information

  Are you or your organization a Certified Historically Underutilized Business? YesNo
  Do you have any relatives who work for or contract with Bluebonnet Trails Community MHMR Center? YesNo
  If yes, list names, relationship and location where employed
  
  In what languages are you able to provide services?
  EnglishSpanishAmerican Sign LanguageSigned EnglishOther

• II. EDUCATION/LICENSING/CREDENTIALS/ACCREDITATIONS:
  Highest Level of Education: High School DiplomaGEDUndergraduateGraduate
  Degree(s)  
  Type of License/Credentials/Certifications/Accreditations of individual/organization
  
  

• III. SERVICE PROVISION INFORMATION:
  Population to be served
  ECIMR/Developmental DelaysAutismMH Child/YouthMH AdultSubstance Abuse Which service(s) are you applying for?
  Supported Home Living/Community SupportsMR RespiteDay Habilitation
  Supported Employment/Employment AssistanceCertified Behavior Analyst (Autism Services)Crisis On-Call
  Psychiatric ServicesIntake AssessmentCognitive Behavioral Therapy
  MH Crisis RespiteSpeech TherapyPhysical Therapy
  Occupational TherapyInterpreter/Translator
  
  Describe number of years and experience in providing this service(s)
  
  In which county(ies) do you wish to provide services? (check all that apply)
  BastropBurnetCaldwellFayetteLeeGonzalesGuadalupeWilliamson
  
  

• IV. INSURANCE
  Type of liability coverage
  NoneProfessionalGeneralHomeownersAuto
  
  

• V. to VII. QUESTIONS
  V. Questions for Providers of Counseling Only

  Do you have your own office space? YesNo
  If yes, where is it located?
  Address
  City
  State
  AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY Zip Code
  

  VI. Questions for Providers of Transportation Only

  Do you have a valid Texas Driver’s License? YesNo
  Do you have current automobile insurance? YesNo
  Is your vehicle wheelchair accessible? YesNo
  

  VII. Questions For Providers Of Respite Only

  Will services be provided in your residence or home? YesNo
  Type of Residence HouseDuplexCondo/TownhomeApartmentMobile Home
  Do you own or rent? OwnRent
  How many persons live with you? Family Members Non-Family Members If you are providing services to a family member, are you interested in providing this service to other consumers of Bluebonnet Trails? YesNo
  Age of consumers you wish to provide services to  
  Gender of consumer you wish to provide services to MaleFemale What days and hours are you available to provide services?
  

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  Background checks are required on all household members 18 years of age and older. Please list all persons residing in your home, other than yourself and the consumer, who are 18 years of age or older. Be prepared to provide copies of their social security card and driver’s license or Texas ID upon request.
  

  	Name	Relationship to Foster Provider	Date of Birth (Mo/Day/Year)
  1.
  2.
  3.
  4.

• VIII. REFERENCES
  Please list three (3) professional references:
  

  1. Name
     Phone
     
     Address
     City
     State
     AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY Zip Code
     
     
  2. Name
     Phone
     
     Address
     City
     State
     AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY Zip Code
     
     
  3. Name
     Phone
     
     Address
     City
     State
     AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY Zip Code
     
     

• IX. AGREEMENT
  Please read the following statements carefully and indicate your understanding and acceptance by checking the box below:
  

  1. I certify that all information provided by me in connection with my application, whether in this form or not, is true and complete, and I understand that any misstatement, falsification, or omission of information shall be grounds for refusal to contract with, or if contracted, termination.
  2. I understand I will be checked with the Texas Department of Public Safety for any criminal history in accordance with applicable statutes. I understand that conviction of any one of these criminal offenses will bar me from contracting.
  3. I understand I will be checked with the Employee Misconduct Registry and Nurse Aid Registry in accordance with applicable statutes. I understand that being listed as revoked in the Nurse Aid Registry or being listed as unemployable in the Employee Misconduct Registry would bar me from contract status.
  4. I authorize any of the persons or organizations referenced in this application to give you any and all information they might have, personal or otherwise, with regard to any of the subjects covered by this application, and I release all such parties from all liability from any damages which may result from furnishing such information to you.
  5. I agree to accept the current rate offered for the position for which I am applying on this date.
  6. I understand that referrals for my services are not guaranteed.

  I AGREE TO THE ABOVE STATEMENTS
  
  

  You must agree to the above statements.