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GCBDD Waiver Waitlist
1.
What is your name?
2.
Date on wait list?
3.
Are you currently enrolled on Medicaid?
Yes
No
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)
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)
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)
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)
8.
Do you currently live with an aging caregiver?
Yes
No
9.
Do you wish to keep your name on the Waiver Waitlist?
Yes
No
10.
Is there anything else you'd like us to know?