GCBDD Waiver Waitlist Question Title * 1. What is your name? Question Title * 2. Date on wait list? Question Title * 3. Are you currently enrolled on Medicaid? Yes No Question Title * 4. What type of waiver services would be beneficial? Check all that apply. Respite Personal Care Transportation (to appointments/recreation) Transportation (to work) Day Programming Job Coaching Behavior Assessment Equipment Nursing Clinical/Therapeutic Intervention Home Modifications Other (please specify) Question Title * 5. When would waiver services be needed? Immediately In 1 to 3 years In 3 to 5 years In 5 to 7 years Other (please specify) Question Title * 6. Where do you see yourself (or your loved one) living in the future? With family In an apartment alone In an apartment with a roommate In a supported living home (with up to 3 other people) In a nursing facility or assisted living facility Other (please specify) Question Title * 7. When would the above residential services be needed? Immediately In 1 to 3 years In 3 to 5 years In 5 to 7 years Other (please specify) Question Title * 8. Do you currently live with an aging caregiver? Yes No Question Title * 9. Do you wish to keep your name on the Waiver Waitlist? Yes No Question Title * 10. Is there anything else you'd like us to know? Done