Oak Tree Farm Survey - Rev. 11/2020

Equal Housing Opportunity

Individual survey responses are confidential and will not be shared with others without permission. This survey will be used to update our records and help us determine the next round of potential residents for Oak Tree Farm, a supported living community for individuals with Autism or an Intellectual Disability. Completing this survey does NOT guarantee or secure a residence.

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* 1. The person completing this survey is (select one):

Self (Potential Resident)

Parent, Sibling, or Other Relative

Legal Guardian

Spouse

Case Manager or Service Provider

Name of person completing survey:

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* 2. Please provide information on potential resident:

Potential Resident's Full Name

Current Street Address

City

State

ZIP

Email Address

Phone Number

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* 3. In what county does the potential resident currently live?

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* 4. What is the potential resident's date of birth? (You must be 18+ to apply to live at Oak Tree Farm)

Birth Date:

Date

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* 5. Does the potential resident have Autism or an Intellectual Disability?

Yes

Please specify diagnosis:

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* 6. What type of assistance does the potential resident currently require? (Select all that apply)

Basic Meal Preparation (cannot use microwave)

Bathing/Showering

Behaviors and/or Anger Issues

Communication

Dressing

Eating

Grocery Shopping

Household chores

Laundry

Managing Money

Medication Reminders

Personal Hygiene Reminders

Stranger Danger

Toileting

Transportation (public or private)

Other (please specify)

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* 7. Can the potential resident be left alone overnight?

Yes

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* 8. Can the potential resident be left alone for at least 8 hours during the day?

Yes

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* 9. Does the potential resident have Medicaid?

Yes

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* 10. Does the potential resident have health insurance?

Yes

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* 11. Is the potential resident receiving services through the ID/RD Waiver or Community Supports Waiver? (respite care, personal caregiver, job coach, day program).

Yes

If yes, please specify:

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* 12. Is the potential resident currently receiving services through the Department of Disabilities and Special Needs or another service provider?

Yes

No, I pay for services privately

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* 13. Is the potential resident currently receiving Social Security benefits?

Yes

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* 14. Are there local supports in place for this individual such as family members or personal caregivers, to assist with personal needs or in emergency situations?

Yes

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* 15. The potential resident will be responsible for paying rent which will be approximately $500 per month. Do you understand this?

Yes

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* 16. What is the potential resident's marital status?

Single

Married

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* 17. Has the potential resident previously lived on his/her own?

Yes

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* 18. Has the potential resident ever been arrested?

Yes

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* 19. In the past two years, has the potential resident experienced issues with any of the following? (Select all that apply)

Destruction of Property

Inappropriate Sexual Behaviors

Running Away/Wandering

Seizures

Self-injury or Injurious Behaviors Toward Others

None of the Above

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* 20. Does the potential resident meet the criteria for low-income housing based on 2020 low-income guidelines? (Extremely Low-Income for 1 person is less than $12,760 per year and Very Low-Income for 1 person is less than $20,400 per year). *Income verification is required for housing at Oak Tree Farm.

Yes

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* 21. Are you willing to assist with fundraising for this project?

Yes

If you answered yes, please provide your name, phone number and email address.