Lev Dov: Home with a Heart.

Jewish Families Needs Assessment

Dear friend,

In consultation with Reena and the Toronto Jewish Disability Network, Lev Dov is reaching out to identify Jewish families who are interested in long-term planning for their loved ones with disabilities. Our first course of action is to undertake a community-wide, comprehensive needs assessment.

The results will give us data to inform our plans and a network of contacts for these services. The survey responses will be limited to these purposes and will remain entirely confidential.

This survey can be completed by those seeking supports for themselves and/or their caregivers and family. If you want to call us to share information or need help answering the survey, please contact us at: info@levdov.com

Thank you for taking the time to complete the survey.

We look forward to hearing from you.

Deborah Jacobs, M.S.W., RSW
Miri Kaufman

Endorsed by:
Rabbi Elliot Diamond, Rabbi of Shaarei Shomayim
Rabbi Yaacov Felder, Rabbi Shomrei Shabbos Congregation
Rabbi Yitzchok Grossbaum, Director, The Friendship Circle
Rabbi Zalman A. Grossbaum, Chabad Lubavitch of Southern Ontario
Rabbi Yehezkel Grysman, Rabbi Zichron Yisroel Congregation
Rabbi Elie Karfunkel, Forest Hill Jewish Centre
Rabbi Daniel Korobkin, Rabbi Beth Avraham Yosef of Toronto (BAYT)
Kathy Laszlo, Executive Director DANI
Rabbi Mordechai Lowy, Rabbi Agudath Israel Congregation
Harav Shlomo Miller, Rosh Kollel, Kollel Avreichim
Rabbi Kalman Ochs, Rabbi Toras Emes Congregation
Rabbi Tzvi Sytner, Rabbi Village Shul
Esther Fink, Physiotherapist, Canadian Medek Centre
Dr. Colin Geft, Community Pediatrician
Bryan Keshen, CEO Reena
Robyn Quint, Board Chair DANI
Yaffi Scheinberg, Executive Director KCC
Dassi Slater, Board of director KCC
Susie Sokol, Founder Toronto Jewish Disability Network, Director Emeritus DANI

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* 1. Relationship to the support-seeking individual

For myself

Parent

Sibling

Friend

Paid caregiver

Child

Other family members

Other (please specify)

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* 2. Date of Birth of individual seeking support

MM/DD/YYYY

Date

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* 3. Present living arrangement of the supported individual:

Parents’ home

Agency managed housing (group home, supported Individual Living (SIL), foster care)

Own apartment/ home

Shared apartment/home

Shelter

Hospital

Long term care

Other family member’s home

Other (please specify)

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* 4. Where geographically does the individual live?

Outside Ontario

Outside of the GTA

GTA

Other (please specify)

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* 5. What financial support, if any, is the individual currently receiving?

ODSP

Passport

Funded agency service

Family funded service

Not receiving financial supports

Other (please specify)

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* 6. Please select any characteristics that apply to the applicant

Able to walk independently

Limited mobility

Verbal

Non-verbal utilizes augmentative communication device

Able to communicate thoughts, emotions, needs

Unable to communicate thoughts, emotions needs

Deaf

visually impaired

Compromised fine motor dexterity

Cognitively delayed

Sensory sensitivity

Mental health condition

Complex behavioural needs

Complex medical needs

Other or if chose "complex medical needs" / "complex behavioural needs" (please specify)

None of the above

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* 7. Current supported ratio at home (individual/support provider)?

1:1

1:2

1:3

Other (please specify)

None of the above

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* 8. Current Supported Ratio at school/ program? (individual/staff)

1:1

2:1

3:1

Other (please specify)

None of the above

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* 9. Type of support needs required:

Personal Hygiene

Eating

Mobility

Social

Behavioral

Healthcare

Other (please specify)

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* 10. Who currently provides these services?

Family member

Support worker

LHIN / Agency support

Other (please specify)

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* 11. How many hours of service does the individual currently receive? (Include family support time: oversight and/or actual involvement)

1-3 hours/day

4-10 hours/day

11-16 hours/day

Requires 24/7 hr care

Other (please specify)

None of the above

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* 12. Can the individual be left unsupervised without family or staff assistance? (if "No", go to question #14)

Yes

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* 13. If “Yes” - for how many hours?

1-2 hours

3-5 hours

Full day

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* 14. How important is a religious connection and/or religious environment to the individual?

It makes no difference

It is a bonus

It is very important

Other (please specify)

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* 15. Please specify what accommodations would meet their religious needs and/or enhance their Jewish cultural experience

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* 16. What would the individual require to feel engaged in their religious practices?

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* 17. How often does the individual participate in Jewish cultural activities in the community?

Daily

Weekly

Monthly

A few times a year or less

Other (please specify)

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* 18. Are there any activities or programs that you think would enhance the cultural aspect of the life of the individual in the community?

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* 19. In your opinion (and on the scale of 1-10) how stable is the individual's long-term housing condition/ solution (Please move the slider to approximate level)

No viable housing plans

Fairly stable housing solutions

Ownership or having their own lease

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 20. What kind of long-term residential solution would best suit the applicant?

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* 21. When would be the ideal time for the individual to transition to their new residence?

Immediately- 5 years now

5-10 years from now

In more than 10 years from now

Other (please specify)

None of the above

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* 22. What barriers have you encountered in trying to set up housing for the individual? Barriers examples: costs, lack of options in the community, lack of religious accommodations, not ready, etc

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* 23. Please mark the areas of interest for the applicant or family

Housing

Vocational training and placement

Family / siblings support

Social and dating programs

Recreational programs

Respite at home

Respite in a safe residence away from home

Transition support (school and work)

Behavioural support programs

Economic advice and assistance

Transportation assistance

Inclusion programs

Other (please specify)

None of the above

Lev Dov: Home with a Heart.

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* 1. Relationship to the support-seeking individual

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* 2. Date of Birth of individual seeking support

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* 3. Present living arrangement of the supported individual:

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* 4. Where geographically does the individual live?

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* 5. What financial support, if any, is the individual currently receiving?

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* 6. Please select any characteristics that apply to the applicant

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* 7. Current supported ratio at home (individual/support provider)?

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* 8. Current Supported Ratio at school/ program? (individual/staff)

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* 9. Type of support needs required:

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* 10. Who currently provides these services?

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* 11. How many hours of service does the individual currently receive? (Include family support time: oversight and/or actual involvement)

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* 12. Can the individual be left unsupervised without family or staff assistance? (if "No", go to question #14)

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* 13. If “Yes” - for how many hours?

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* 14. How important is a religious connection and/or religious environment to the individual?

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* 15. Please specify what accommodations would meet their religious needs and/or enhance their Jewish cultural experience

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* 16. What would the individual require to feel engaged in their religious practices?

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* 17. How often does the individual participate in Jewish cultural activities in the community?

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* 18. Are there any activities or programs that you think would enhance the cultural aspect of the life of the individual in the community?

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* 19. In your opinion (and on the scale of 1-10) how stable is the individual's long-term housing condition/ solution (Please move the slider to approximate level)

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* 20. What kind of long-term residential solution would best suit the applicant?

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* 21. When would be the ideal time for the individual to transition to their new residence?

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* 22. What barriers have you encountered in trying to set up housing for the individual? Barriers examples: costs, lack of options in the community, lack of religious accommodations, not ready, etc

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* 23. Please mark the areas of interest for the applicant or family

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* 24. Respondent First Name

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* 25. Respondent Last Name

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* 26. Email address

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* 27. Please share any other comment/observation/opinion that you did not express thus far. Thank you.

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* 28. What synagogue/community are you affiliated with?