ARCH In-Home Residential Care (RESPITE) Survey Fiscal Year 2020

PLEASE NOTE: The funding source of in-home residential care supports (respite) requires us to have a survey on each individual receiving services. You will need to complete a separate survey for each family member receiving services through ARCH. Information obtained in these surveys will remain confidential.

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* 1. Participant Information

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* 2. Parent/Guardian Information (residing at same address as consumer)

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* 3. Is the Parent/Guardian over 60 years of age?

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* 4. 2nd Contact Person or Parent Information- skip if not applicable

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* 7. Are you receiving any services funded through the Missouri Department of Mental Health/Regional Office or Medicaid?

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* 8. How do you utilize your ARCH in-home residential care (respite)?  Check all that apply.

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* 9. Do you use any other in-home residential care (respite) programs besides ARCH?

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* 10. Which services/supports does your family member with a developmental disability receive? Please check all that apply.

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* 12. How much do you pay your providers per hour?

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* 13. Who do you generally use as care providers?  Check all that apply.

The following information is used to help us determine how many hours of care to assign your family.

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* 14. Does your family member with a developmental disability have any medical/health problems at the present time?

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* 15. Does your family member with a developmental disability have behaviors that increase your need of ARCH in-home residential care?

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* 16. Are there any health problems with the parent/guardian of this consumer?

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* 17. Are there any problems or circumstances in your home at the present time that would increase your need for ARCH in-home residential care?

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* 18. Do you consider the out-of-home placement for your family member with a developmental disability to be a critical need (meaning in the next 1-2 years)?

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* 19. If you have not used in-home residential care (ARCH respite services) in the past 1-3 years, please give reason(s) why:

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* 20. What additional comments do you have for us?

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* 21. Name of person completing this survey:

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