Consumer Directed Services (CDS)

Consumer Directed Services (CDS) Application

Prefix

First Name

Middle Name

Last Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Country

PHONE NUMBERS HM

Cell

Alt

Social Security Number

Date of Birth

HAVE YOU USED AN ALIAS?YesNo

If YES, list ALL aliases you have used (please include maiden names, married names, and other legal name changes).

HAVE YOU USED ANY OTHER SOCIAL SECURITY NUMBERS?YesNo

If YES, list ALL social security numbers you have ever used.

3. HAVE YOU HAD ANY OF THE FOLLOWING IN MISSOURI OR IN ANY OTHER STATE: criminal convictions, findings of guilt, pleas of guilty, and pleas of nolo contendere?YesNo

If YES, list ALL criminal convictions, findings of guilt, pleas of guilt, and pleas of nolo contendere AND the state in which this occurred. Do not list minor traffic offenses such as speeding tickets and parking tickets. Please use the next page (5) to list.

4. DO YOU GIVE CONSENT TO A PRE-EMPLOYMENT CRIMINAL RECORD CHECK?YesNo

5. DO YOU GIVE CONSENT TO A CLOSED BACKGROUND CHECK, PURSUANT TO SECTION 610.120 RSMo?YesNo

I certify that all the information provided by me on this application and accompanying documents is true and complete. I understand that false representation or omission of any fact will be cause for denial of employment or termination of employment. In consideration for employment.I agree to abide by the CDS CONSUMER'S NAME rules, regulations, policies and procedures of Secure Home Healthcare Services LLC the Missouri Department of Health and Senior Services, the Missouri Department of Social Services and the State of Missouri. I further understand that I am not considered at any time an employee of Secure Home Healthcare Services LLC, Missouri Department of Health and Senior Services, Missouri Department of Social Services or the State of Missouri. If I am hired, I understand that I am an employee of only for the period subsidized with Consumer Directed Services funds

Applicant's Full Name

Date

About Us

As expressed by local physicians, there is a strong need for quality In-Home Healthcare Services. The United States is expected to see an increase in the demand for home health and personal care as the population ages. Secure Home Healthcare Services is focused on making an impact in you and/or your loved one’s lives.

Services

Personal Care

Meal Prep/Planning

Mobility/Transfer

Alzheimers/Dementia care

Respite Care

Healthy Children/Youth Program

Advance Personal Care

Authorized Nurse Visits

Homemaker Services & Laudry

Companionship/Social And More

Contact us

134 Enchanted Parkway, Suite 203, Manchester, MO 63021
(636) 220 1220
1-800-924-4916
(636) 220-0020
info@securehomehealthcareservices.com
www.securehomehealthcareservices.com

Serving areas

St. Louis City and Country, St. Charles City and County, Wentzville, Lincoln, Pacific, St. Genevieve, Cape Girardeau, Jefferson, St. Clair, Warren, Washington, and surrounding areas.