www.thelifevillage.net

LIFE Village Inc. is developing an affordable, inclusive, and supportive residential community for adults with autism and related Intellectual and Developmental Disorders.  LIFE House is an initiative that will start LIFE Village on a smaller scale with rental home options.  This model will provide housing for two adults with a diverse ability and one live-in support staff (Residential Support Staff or RSS).  The future prospective resident should fill out this survey, with assistance from your parent(s) or guardian if needed, so that we can start the process of identifying interested residents.  **Please note: this survey does not guarantee a rental agreement and/or support services from LIFE Village Inc. nor should it be considered a waiting list.  The intention of this survey is to help LIFE Village and LIFE House to develop the most appropriate programming and services, and to identify those individuals who are interested in this supportive living model.

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* 1. What is your current age and gender?

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* 2. Do you have an autism or similar Intellectual or Developmental diagnosis or do you identify as being autistic without a diagnosis?  If so, what is your professional diagnosis or how do you identify your neurodiversity?  If this does not apply to you, write none in the box.

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* 3. How do you currently spend your day?  Check all that apply.

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* 4. What support services do you currently have available to you?

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* 5. What kind of other support, services, or resources will help develop your independence and help you live your best life?  Check all that apply.

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* 6. What kind of transportation do you require?

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* 7. LIFE House will have a live-in support person (RSS) and two renters with an autism or similar diagnosis, would this be an ideal living situation for you?

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* 8. Please use this space to tell us more about you and the place that you currently live and call home.  Where do you want to live in the future?  Would you like to live in a supportive residential house like LIFE House with a roommate and a support person?  Are you ready now?  If not, what do you need to do to prepare for this change and when would you be ready?

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* 9. Given the resources that you have available to you, and considering that a live-in support person would be available, what would you consider an affordable and reasonable monthly rent (including utilities)?

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* 10. What is your contact information? (Please be sure to populate every field even if it does not apply)

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