West Virginia Bureau for Children and Families - Adult Residential Services

Adult Family Care/Emergency Shelter Care Inquiry Form

Please take time to fill out our Adult Family Care/Adult Emergency Shelter Care inquiry form. The West Virginia Bureau for Children and Families does not sell, rent, loan, trade or lease any information collected on our site. For more details please review the WVDHHR Privacy Policy.

Have you ever been an Adult Family Care or Adult Emergency Care Provider? Yes No

If yes, what city and state were you licensed in? City State

What is your gender? Female Male

What is your current marital status? Single Married Widow Divorced

Would you consider taking an adult that, May be mentally handicapped May have emotional problems May have medical problems May have behavioral problems

Do you have any special training, i.e. medical, mental health? Type of Training

Would you be willing to particpate in training to learn new skills and expand your knowledge about caring for adults? Yes No

Are you interested in learning more about becoming an Adult Family Care and/or Emergency Shelter Care? Yes No

This information will be given to the Adult Services Unit in your county. Would you like to have someone call you with more information on becoming an Adult Family Care Provider? Yes No

This information will be given to the Adult Services Unit in your county. Would you like to have someone call you with more information on becoming an Adult Emergency Shelter Family Care Provider? Yes No

Your Name:

Your Email Address:

Your Address:

City:

County:

State:

Zipcode:

Daytime Phone: (xxx)xxx-xxxx

Evening Phone: (xxx)xxx-xxxx

Please review your information for accuracy and click submit.

General Info

Search

Related Sites

Adult Family Care/Emergency Shelter Care Inquiry Form