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):

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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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* 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).

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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?

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