ARCH Family In-Home Residential Care Survey

PLEASE NOTE: The funding source of in-home residential care supports now 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.

Question Title

* 1. Consumer Information

First Name

Last Name

Age

Primary Disability

Address

City

State

Zip Code

Home Phone

Question Title

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

Parent/Guardian Name

Cell Phone

Email Address

Place of Employment

Work Phone

Relationship to Consumer

Question Title

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

Yes

Question Title

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

Contact Name

Relationship to Consumer

Address

City

State

Zip Code

Home Phone

Cell Phone

Email Address

Place of Employment

Question Title

* 5. How many adults (18 & older) reside in the household?

Question Title

* 6. How many children (17 and under) reside in the household?

Question Title

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

Yes

Question Title

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

Brief breaks

Socialization/outings

Emergencies only

Routine/scheduled

Vacations

Weekends

Overnights

Days

Evenings

Other, please specify

Question Title

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

Yes

If yes, please indicate which program(s):

Question Title

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

In-Home Residential Care

Adult Day Program

Special School District

Summer Camp

Personal Care Assistance

Nursing care

Nanny care

Sheltered Workshop

Supportive Employment

Competitive Employment

Preschool or Day Care

Before/after school care

Adult Day Care

Recreation Programs

Other, please specify

Question Title

* 11. How many in-home residential care providers do you use?

Question Title

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

Question Title

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

Family Member (older than 16 residing outside the home)

Friend

Neighbor

Church/synagogue member

Teacher

Other, please specify

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

Question Title

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

Yes

If yes, please explain

Question Title

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

Yes

If yes, please explain

Question Title

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

Yes

If yes, please explain

Question Title

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

Yes

If yes, please explain

Question Title

* 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)?

Yes

Question Title

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

Unable to find a provider

Saving for emergencies only

Unable to afford care even with reimbursement from the program

Unable/haven't completed paperwork to get reimbursed

Other (please specify)

Question Title

* 1. Consumer Information

Question Title

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

Question Title

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

Question Title

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

Question Title

* 5. How many adults (18 & older) reside in the household?

Question Title

* 6. How many children (17 and under) reside in the household?

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 11. How many in-home residential care providers do you use?

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 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)?

Question Title

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

Question Title

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

Question Title

* 21. Name of person completing this survey: