Residential Community Survey

Independence Landing

Independence Landing Inc is a non-profit corporation created by concerned parents of young adults with special needs in Tallahassee, FL. Its aim is to build a new housing option for disabled individuals who can live independently with some support from the community, fellow residents, family, friends and/or caregivers. Our vision is a planned, affordable and safe residential campus with amenities that would allow residents to successfully lead independent and fulfilled lives. This will not be a group home. It will be similar to a town-home or upscale apartment-style living.

As part of our mission to develop a supportive, protected and fair housing for future residents, we ask your participation in filling out this survey. Your input is crucial to the planning, implementation and evaluation of this community housing program.

The information that you provide will be kept strictly confidential. Submitting this survey WILL NOT determine eligibility, secure placement nor put you on the waiting list. If you have received this survey from more than one source, please complete it only once.

Thank you for sharing your ideas with us as we find solutions that address future residents’ unique needs and preferences.

The following questions should reflect the personal views and choices of the individual with special needs. The person completing this survey on behalf of the applicant will need to provide their contact information at the end of the survey.

Question Title

* 1. The person completing this survey is: (please select one)

Self

Parent, Sibling, or Other Relative

Legal Guardian (Court Appointed)

Spouse

Support Coordinator or Service Provider

Other (please specify)

Question Title

* 2. Please provide the information of interested resident.

Interested Resident's Name

Current Address:

Current Address 2:

City/Town:

State:

Zip:

Email Address:

Question Title

* 3. What state COUNTY do you currently live?

Question Title

* 4. What is the date of birth of Interested Resident?

Interested Resident DOB: (MM/DD/YYYY)

Date

Question Title

* 5. Which of the following best describes the Interested
Resident’s disability? (Please check all that may apply.)

Developmental or Intellectual/cognitive disability

Spina Bifida

Cerebral Palsy

Prader-Willi Syndrome

Autism Disorder

Downs Syndrome

Asperger's Syndrome

Physical Disability

Traumatic Brain Injury

Visually Impaired

Hearing Impaireded

Mental Illness

Other (please specify)

Question Title

* 6. What support or assistance do you currently need? (Please check all that may apply.)

Dressing

Basic meal preparation

Eating

Showering/Bathing

Personal hygiene reminders

Toileting

Managing money

Laundry

Household chores/keeping room clean

Transportation (public or private)

Taking medications

Grocery shopping

Communication

Behaviors and anger Issues

Stranger Danger

Personal Danger

Other (please specify)

Question Title

* 7. What period of time can you be left unsupervised and
alone?

I need 24 hour supervision and/or support

1 to 3 hours

4 to 6 hours

7 to 12 hours

13 to 16 hours

Several Days

Several Weeks at a Time

Question Title

* 8. Are you currently receiving Medicaid Home & Community
Based Waiver Services?

Yes

No, I'm on the waiting list through the Agency for Persons with
Disabilities?

No, I pay for services privately

Question Title

* 9. What is your current living situation?

Family home with parents/relatives

My own home with relatives

My own home by myself

My own home with non-relatives

Foster or adult companion home

Group home

Assisted-living or nursing home

Other (please specify)

Question Title

* 10. What is your marital status?

Married

Widowed

Divorced

Separated

Engaged

Never Married

Question Title

* 11. Have you previously lived on your own?

Yes

Question Title

* 12. Have you ever been Baker Acted, Marchman, Ex Parte,
Parens Patriae committed or arrested?

Yes

Question Title

* 13. In the past five years, have you experienced issues with: (Please check all that may apply.)

Inappropriate Sexual Behaviors

Running Away

Self-Injurious

Injurious Behaviors Towards Others

Destruction of Property

Seizures

None of the Above

Question Title

* 14. What support services are you currently receiving at home and/or from service provider/s?
(Please check all that may apply.)

Adult Day Training

Behavioral Counseling

Companion

Durable Medical Supplies

Medication Administration

Personal Supports

Residential Habilitation

Supported-Employment

Supported-Living

Transportation

Other (please specify)

Question Title

* 15. Have you considered other possible residential options?

I have not looked at other residential options.

I have considered living independently with outside support in
the community.

I have considered licensed establishments like group homes,
assisted living facilities, and nursing homes.

Question Title

* 16. What type of dwelling would you prefer : (check only
one)

In my own apartment by myself

In a two-bedroom apartment with a room-
mate

In a two-bedroom apartment by myself

Question Title

* 17. What is the maximum amount that you could afford for
monthly rent and utilities?

$301 - $400 (including utilities)

$401 - $500 (including utilities)

$501 - $600 (including utilities)

$601 - $700 (including utilities)

$701 - $800 (including utilities)

$801 - $900 (including utilities)

$901 - $1000 (Including utilities

Over $1000 (including utilities)

Question Title

* 18. Based upon the estimated rents established by the
Florida Housing Tax Credits Program, which living
arrangement best fits your budgetary situation?

$585 per month (est.) for my own one-bedroom apartment (plus support services)

$351 per month (est.) for a shared-living two-bedroom apartment (plus support services)

Question Title

* 19. How soon would you be ready to move? (check only
one)

Within 2 years

Within 3 years

Within 4 years

Within 5-7 years

Within more than 7 years

Question Title

* 20. What are your monthly sources of income and benefits?
(Please check all that may apply.)

Supplemental Security Income (SSI)

Social Security (SSA)

Social Security Disability Income (SSDI)

Medicaid/Medicare

Food Stamps

Income From Job

Special Needs Trust

Family Trust

None

Other (please specify)

Question Title

* 21. What is your total monthly income? (choose the closest
number)

Less than $700

$700

$800

$900

$1000

$1100

$1200

$1300+

Question Title

* 22. Do you work or participate in any of the following daily
activities? (check only one)

Yes, I work in the community and get paid.

Yes, I work at an adult training center and get paid.

Yes, I volunteer but do not get paid.

No, but I am actively seeking employment.

No, I am not interested or unable to be employed.

Question Title

* 23. How many hours per week (average) do you work or
volunteer? (check only one)

Not Applicable

1 - 5

6-10

11-15

16-20

21-25

26-30

31-35

36-40

Question Title

* 24. How long have you been employed or have volunteered?

Not Applicable

Less than 1 year

1 - 2 Years

3 - 4 Years

5 - 10 Years

Over 10 Years

Question Title

* 25. Please rank the following services and choices in terms of importance to you:

	Very Important	Important	Not Important	Not At All Important
Daytime Activities	Daytime Activities Very Important	Daytime Activities Important	Daytime Activities Not Important	Daytime Activities Not At All Important
Recreation & Social Activities	Recreation & Social Activities Very Important	Recreation & Social Activities Important	Recreation & Social Activities Not Important	Recreation & Social Activities Not At All Important
Job Skill Training	Job Skill Training Very Important	Job Skill Training Important	Job Skill Training Not Important	Job Skill Training Not At All Important
Employment Opportunities	Employment Opportunities Very Important	Employment Opportunities Important	Employment Opportunities Not Important	Employment Opportunities Not At All Important
Continuing Education	Continuing Education Very Important	Continuing Education Important	Continuing Education Not Important	Continuing Education Not At All Important
On-Site Dining	On-Site Dining Very Important	On-Site Dining Important	On-Site Dining Not Important	On-Site Dining Not At All Important
Living With or Close to My Family & Friends	Living With or Close to My Family & Friends Very Important	Living With or Close to My Family & Friends Important	Living With or Close to My Family & Friends Not Important	Living With or Close to My Family & Friends Not At All Important
Personal Safety	Personal Safety Very Important	Personal Safety Important	Personal Safety Not Important	Personal Safety Not At All Important
Life Skill Training	Life Skill Training Very Important	Life Skill Training Important	Life Skill Training Not Important	Life Skill Training Not At All Important
Medication Supervision and Administration	Medication Supervision and Administration Very Important	Medication Supervision and Administration Important	Medication Supervision and Administration Not Important	Medication Supervision and Administration Not At All Important
Transportation	Transportation Very Important	Transportation Important	Transportation Not Important	Transportation Not At All Important

Other (please specify)

Question Title

* 26. Are you willing to move to our Tallahassee location from your current
residence?

Yes

Question Title

* 27. What amenities or features are important to have within
the community?

Recreational/Community Center

Pool/Jacuzzi

Fitness Center

Basketball Court

Tennis Court

Computer Lab/Internet Cafe

Arcade/video games

Community Dining

On-site Businesses

Laundry Facility

Safety/Security Measures

Other (please specify)

Question Title

* 28. When was your primary caregiver born?

Caregiver's Birth Date (MM/DD/YYY):

Date

Question Title

* 29. Would you like to receive our email newsletter and
updates?

Yes

Question Title

* 30. The date this survey was completed:

Date / Time

Date

Question Title

* 31. Would you be interested in volunteering in Independence Landing’s
project? Become part of our community and experience the joy and
gratification of enhancing the lives of Independent Landing residents.
You will be matched to an assignment based on your skills, talents and
interests.

Yes

Write Your areas of Interest here:

Question Title

* 32. Would you consider donating to this planned residential
community for individuals with special needs?
Fundraising will remain a critical factor in order to complete this
this project. Our ongoing effort to address the unprecedented and intensive
housing needs of this vulnerable population, will give them a
place where they have a sense of community and belonging.
Thank you for your support.

Yes

Question Title

* 33. Contact information for the person assisting individual with
special needs in completing this survey:

Name:

Company:

Address:

Address 2:

City/Town:

State:

ZIP:

E-Mail Address:

Telephone with Area Code:

Alternate Telephone with Area Code

Question Title

* 1. The person completing this survey is: (please select one)

Question Title

* 2. Please provide the information of interested resident.

Question Title

* 3. What state COUNTY do you currently live?

Question Title

* 4. What is the date of birth of Interested Resident?

Question Title

* 5. Which of the following best describes the InterestedResident’s disability? (Please check all that may apply.)

Question Title

* 6. What support or assistance do you currently need? (Please check all that may apply.)

Question Title

* 7. What period of time can you be left unsupervised andalone?

Question Title

* 8. Are you currently receiving Medicaid Home & CommunityBased Waiver Services?

Question Title

* 9. What is your current living situation?

Question Title

* 10. What is your marital status?

Question Title

* 11. Have you previously lived on your own?

Question Title

* 12. Have you ever been Baker Acted, Marchman, Ex Parte,Parens Patriae committed or arrested?

Question Title

* 13. In the past five years, have you experienced issues with: (Please check all that may apply.)

Question Title

* 14. What support services are you currently receiving at home and/or from service provider/s?(Please check all that may apply.)

Question Title

* 15. Have you considered other possible residential options?

Question Title

* 16. What type of dwelling would you prefer : (check onlyone)

Question Title

* 17. What is the maximum amount that you could afford formonthly rent and utilities?

Question Title

* 18. Based upon the estimated rents established by theFlorida Housing Tax Credits Program, which livingarrangement best fits your budgetary situation?

Question Title

* 19. How soon would you be ready to move? (check onlyone)

Question Title

* 20. What are your monthly sources of income and benefits?(Please check all that may apply.)

Question Title

* 21. What is your total monthly income? (choose the closestnumber)

Question Title

* 22. Do you work or participate in any of the following dailyactivities? (check only one)

Question Title

* 23. How many hours per week (average) do you work orvolunteer? (check only one)

Question Title

* 24. How long have you been employed or have volunteered?

Question Title

* 25. Please rank the following services and choices in terms of importance to you:

Question Title

* 26. Are you willing to move to our Tallahassee location from your currentresidence?

Question Title

* 27. What amenities or features are important to have withinthe community?

Question Title

* 28. When was your primary caregiver born?

Question Title

* 29. Would you like to receive our email newsletter andupdates?

Question Title

* 30. The date this survey was completed:

Question Title

* 31. Would you be interested in volunteering in Independence Landing’sproject? Become part of our community and experience the joy andgratification of enhancing the lives of Independent Landing residents. You will be matched to an assignment based on your skills, talents andinterests.

Question Title

Question Title

* 33. Contact information for the person assisting individual withspecial needs in completing this survey:

* 5. Which of the following best describes the Interested
Resident’s disability? (Please check all that may apply.)

* 7. What period of time can you be left unsupervised and
alone?

* 8. Are you currently receiving Medicaid Home & Community
Based Waiver Services?

* 12. Have you ever been Baker Acted, Marchman, Ex Parte,
Parens Patriae committed or arrested?

* 14. What support services are you currently receiving at home and/or from service provider/s?
(Please check all that may apply.)

* 16. What type of dwelling would you prefer : (check only
one)

* 17. What is the maximum amount that you could afford for
monthly rent and utilities?

* 18. Based upon the estimated rents established by the
Florida Housing Tax Credits Program, which living
arrangement best fits your budgetary situation?

* 19. How soon would you be ready to move? (check only
one)

* 20. What are your monthly sources of income and benefits?
(Please check all that may apply.)

* 21. What is your total monthly income? (choose the closest
number)

* 22. Do you work or participate in any of the following daily
activities? (check only one)

* 23. How many hours per week (average) do you work or
volunteer? (check only one)

* 26. Are you willing to move to our Tallahassee location from your current
residence?

* 27. What amenities or features are important to have within
the community?

* 29. Would you like to receive our email newsletter and
updates?

* 31. Would you be interested in volunteering in Independence Landing’s
project? Become part of our community and experience the joy and
gratification of enhancing the lives of Independent Landing residents.
You will be matched to an assignment based on your skills, talents and
interests.

* 33. Contact information for the person assisting individual with
special needs in completing this survey: