Choosing a Place to Belong

1. Choosing a Place to Belong

The creators of this survey acknowledge that living in a planned residential community is very much an individual's personal choice. A person wishing to live independently should explore all types of available living arrangements in order to make an informed decision.

This survey assumes that you have explored other options and have an interest in living in a planned residential community that is designed to be sensitive and responsive to the needs and desires of individuals with special needs.

Individual survey responses are confidential, the results of the survey will be used to help organizations make decisions on what amenities should be included in their communities and to advocate for appropriate support services.

Some of the questions mention the word "you"; it is here that we intend to poll the actual person who has special needs that is interested in living in the planned residential community. If you are the caregiver, you may answer for that person.

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* 1. First Name of potential Promise resident

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* 2. Last Name of potential Promise Resident

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* 3. The person completing this survey is a

Potential resident of a planned community designed for individuals with special needs

Family member

Legal guardian

Other

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* 4. The person for whom this survey is being completed would mostly be interested in living in the following area(s)

Promise in Brevard County

The Villages at Noah’s Landing in Lakeland

The Hodges Community in Jacksonville

The Loveland Center in Venice

A planned community in a different area of Florida (please mention city in box below)

City (please specify)

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* 5. Please check the box that most closely matches the age of the resident.

under 18

18 - 24 years

25 - 30 years

31 - 35 years

36 - 40 years

41 - 45 years

46 - 50 years

51 - 55 years

56 - 60 years

over 60 years

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* 6. Please check the age group which mostly closely matches the age of CAREGIVER for the potential resident.

36 - 40 years

41 - 45 years

46 - 50 years

51 - 55 years

56 - 60 years

61 - 65 years

66 - 70 years

71 - 75 years

76 - 80 years

80 years or older

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* 7. What is the type of special need (choose all that apply)?

Developmental

Visual

Hearing

Physical

Traumatic Brain Injury

Mental Illness (specify below)

Other

If other or mental illness please specify

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* 8. What type of assistance do you need (check all that apply)?

help with dressing

help with meals

help with showering

help with money

help with transportation

emotional encouragement

daily living cognitive skills/support

help with medication

Other (please specify)

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* 9. If given a choice, you would prefer to live:

in my own apartment, by myself

in a two bedroom apartment with a room mate

have my own bedroom and bath, but share the living room, dining room, and kitchen with other room mates

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* 10. I would prefer to:

own my apartment

rent my apartment

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* 11. The price range that I could afford to pay each month:

$200 - $300

$300 – $400

$400 - $500

$500 - $600

$600 – $700

$700 – $800

$800 – $900

$900 - $1,000

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* 12. I would prefer to own my one or two bedroom apartment and I could afford to pay:

$50,000 - $69,000

$70,000 – $89,000

$90,000 – $109,000

$110,000 – $129,000

$130,000 -$149,000

$150,000 – $170,000

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* 13. Are you currently on the Medicaid Waiver?

yes

on waiting list

What is the Medicaid Waiver program?

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* 14. If on the Medicaid Waiver, which level?

Tier 4

Tier 3

Tier 2

Tier 1

CDC+

iBudget

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* 15. Where do you currently live?

with my family

in a group home

in a supported-living apartment

in a supported-living home

in a foster care home

Other (please specify)

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* 16. How soon would you like to be living on your own?

right now

1-2 years

3-5 years

5 years or more from now

not sure

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* 17. Please rank the following opportunities and services in terms of importance to you at your future residence:

	Very Important	Important	Somewhat Important	Not Important
Transportation	Transportation Very Important	Transportation Important	Transportation Somewhat Important	Transportation Not Important
Job opportunities	Job opportunities Very Important	Job opportunities Important	Job opportunities Somewhat Important	Job opportunities Not Important
Recreational activities	Recreational activities Very Important	Recreational activities Important	Recreational activities Somewhat Important	Recreational activities Not Important
Continuing education	Continuing education Very Important	Continuing education Important	Continuing education Somewhat Important	Continuing education Not Important
Living with my friends	Living with my friends Very Important	Living with my friends Important	Living with my friends Somewhat Important	Living with my friends Not Important
On-site Meaningful Daytime activity	On-site Meaningful Daytime activity Very Important	On-site Meaningful Daytime activity Important	On-site Meaningful Daytime activity Somewhat Important	On-site Meaningful Daytime activity Not Important
Cook my own food	Cook my own food Very Important	Cook my own food Important	Cook my own food Somewhat Important	Cook my own food Not Important

Other (please specify)

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* 18. What services or features would you like to have within your community?

pool and jacuzzi

workout gym

restaurant /community dining

hair salon

arcade and video games

basketball court

tennis court

access to a computer

laundry room

my own washer /dryer

send laundry to a service

measures to ensure safety

Further ideas

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* 19. Please give us your thoughts, comments and feedback here.

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* 20. It is important that we have your contact information so that we can keep you informed as new planned communities are being developed around the state. Your personal information will remain strictly confidential.

Name: *

Address:

Address 2:

City/Town: *

State: *

ZIP: *

County

Email Address: *

Phone Number: