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):

Self (Applicant)

Parent, Sibling, or Other Relative

Legal Guardian

Spouse

Case Manager or Service Provider

Other (please specify)

* 2. Please provide information on Applicant:

Applicant's Name

Current Street Address

City

State

ZIP

Email Address

Phone Number

* 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

MM /

DD /

YYYY

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

Autism Spectrum Disorder

Developmental or Intellectual Disability

Other (please specify)

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

Basic Meal Preparation (cannot use microwave)

Bathing/Showering

Behaviors and/or Anger Issues

Communication

Dressing

Eating

Grocery Shopping

Household chores

Laundry

Managing Money

Medication Reminders

Personal Hygiene Reminders

Stranger Danger

Toileting

Transportation (public or private)

Other (please specify)

* 7. How long can you be left alone?

I cannot be left alone

1-3 hours

4-6 hours

7-12 hours

13-16 hours

Several Days

Several Weeks at a Time

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

Yes

What is the Department of Disabilities and Special Needs (Contact SOS Health Care for more information)

No, I pay for services privately

* 9. Do you have Medicaid?

Yes

* 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).

Yes

What is a waiver? (Contact SOS Health Care for more information)

* 11. What is your marital status?

Single

Married

* 12. Have you previously lived on your own?

Yes

* 13. Have you ever been arrested?

Yes

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

Destruction of Property

Inappropriate Sexual Behaviors

Running Away/Wandering

Seizures

Self-injury or Injurious Behaviors Toward Others

None of the Above

* 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)

* 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?