The Roommate Housing Option (RHO) is created to increase the availability of quality community housing to individuals with disabilities.    The RHO will group 2 or more individuals together of similar interest and abilities.  These homes will be in local neighborhoods with supports so individuals can live as independently as possible while ensuring health and safety needs are met.  

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* 1. Please complete

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* 2. Do you have a guardian?

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* 3. Guardian's information

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* 4. What is your age?

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* 5. What is your sex?

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* 6. What is your intrest level?

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* 7. Do you have Arkansas Medicaid?

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* 8. Do you currently receive Community/Employment Support Waiver Services?

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* 9. Who is your current Community/Employment Support Waiver Services provider?

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* 10. Are you currently on the Community/Employment Support Wavier Services waiting list?

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* 11. What PASSE are you associated with?

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* 12. Who is your Care Coordinator?

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* 13. I already know someone I would like to have for a roommate(s).

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* 14. What is your current living situation?

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* 15. Do you have a preferred area you wish to live in?

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* 16. Have you lived independently prior to this application?

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* 17. I prefer to live with

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* 18. Do you prefer to have your roommate(s) in your age range?

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* 19. What are you hoping for in a roommate(s)?

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* 20. Which statement best reflects you sleep schedule preferences?

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* 21. In terms of personality, I would describe myself as:

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* 22. How would others describe you?

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* 23. In terms of personality, I would like a roommate who is

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* 24. When dealing with conflicts:

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* 25. When a conflict arises, how do you prefer to communicate the issue?

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* 26. How often do you plan on having guests over?

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* 27. How often do you prefer your roommate have guest over?

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* 28. What term best describes the frequency of your alcohol use

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* 29. Do you mind if your roommate drinks alcohol?

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* 30. Do you smoke?

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* 31. Do you mind if your roommate smokes?

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* 32. I keep my personal space organized and free of clutter.

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* 33. How do you feel about borrowing or sharing items?

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* 34. Do you have pets?

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* 35. Which of the following would you mind if your roommate(s) has for a pet?

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* 36. I enjoy preparing my own meals? 

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* 37. I am willing to prepare food for my roommate(s)?

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* 38. Are you on a special diet?

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* 39. Do you have allergies?

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* 40. What are your daily activities?

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* 41. Are you currently employed?

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* 42. What is your net income?

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* 43. How much are you willing to pay for your monthly rent?

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* 44. If you are not employed are you interested in obtaining employment?

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* 45. Would you need any reasonable modification/accommodation?  If "yes" please explain.

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* 46. What type of staff do you prefer to support you?

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* 47. How did you hear about us?

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* 48. What agency referred you to Easterseals?

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* 49. What website/social Media did you visit to find out about our program?

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* 50. Who did you hear about our program from?

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* 51. Do you have any other comments, questions, or concerns?

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