Oak Tree Farm Preliminary Survey

Individual survey responses are confidential and will not be shared with others without permission.  Oak Tree Farm is a ten-year project.  This survey is the FIRST step in the application process.  Completing this survey does NOT guarantee or secure a residence.  Applicant's must be 18+ to live at Oak Tree Farm.  Do NOT fill out this survey if applicant is not at least 18 year's old.  

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

* 2. Please provide information on Applicant:

* 3. In what county do you currently live?

* 4. What is the Applicant's date of birth? (You must be 18+ to live at Oak Tree Farm)

Date 
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* 5. How would you best describe your type of "special needs"? (Check all that apply)

* 6. What type of assistance do you currently require?

* 7. How long can you be left alone?

* 8. Are you currently receiving services through the Department of Disabilities and Special Needs or another service provider?

* 9. Do you have Medicaid?

* 10. Are you receiving services through the ID/RD Waiver or Community Supports Waiver? (If you require caretaker support for more than one hour, you may be required to have waiver services or prove the ability to privately pay for services to live at Oak Tree Farm).

* 11. What is your marital status?

* 12. Have you previously lived on your own?

* 13. Have you ever been arrested?

* 14. In the past two years, have you experienced issues with: (Select all that apply)

* 15. How did you hear about Oak Tree Farm?

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