Oak Tree Farm Preliminary Survey

Individual survey responses are confidential and will not be shared with others without permission. Oak Tree Farm is a multi-phase project. This survey is the FIRST step in the application process. Completing this survey does NOT guarantee or secure a residence. Potential residents must be 18+ to live at Oak Tree Farm. DO NOT COMEPLETE THIS SURVEY if potential resident is not at least 18 years old.

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

Self (Potential Resident)

Parent, Sibling, or Other Relative

Legal Guardian

Spouse

Case Manager or Service Provider

Other (please specify)

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* 2. Please provide information on potential resident:

Potential Resident's Name

Current Street Address

City

State

ZIP

Email Address

Phone Number

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* 3. In what county does the potential resident currently live?

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* 4. What is the potential resident'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 the potential resident's type of "special needs"? (Check all that apply)

Autism Spectrum Disorder

Developmental or Intellectual Disability

Other (please specify)

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* 6. What type of assistance does the potential resident currently require? (Select all that apply)

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)

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* 7. How long can the potential resident 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

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* 8. Is the potential resident 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

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* 9. Does the potential resident have Medicaid?

Yes

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* 10. Is the potential resident receiving services through the ID/RD Waiver or Community Supports Waiver? (If the potential resident requires 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)

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* 11. What is the potential resident's marital status?

Single

Married

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* 12. Has the potential resident previously lived on his/her own?

Yes

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* 13. Has the potential resident ever been arrested?

Yes

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* 14. In the past two years, has the potential resident experienced issues with any of the following? (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

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* 15. Is the potential resident currently receiving SSI or SSDI?

Yes

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

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* 2. Please provide information on potential resident:

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* 3. In what county does the potential resident currently live?

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

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* 5. How would you best describe the potential resident's type of "special needs"? (Check all that apply)

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* 6. What type of assistance does the potential resident currently require? (Select all that apply)

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* 7. How long can the potential resident be left alone?

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* 8. Is the potential resident currently receiving services through the Department of Disabilities and Special Needs or another service provider?

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* 9. Does the potential resident have Medicaid?

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* 11. What is the potential resident's marital status?

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* 12. Has the potential resident previously lived on his/her own?

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* 13. Has the potential resident ever been arrested?

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* 14. In the past two years, has the potential resident experienced issues with any of the following? (Select all that apply)

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* 15. Is the potential resident currently receiving SSI or SSDI?

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