Exit this survey ARCH Family In-Home Residential Care Survey - FY 2016 PLEASE NOTE: The funding source of in-home residential care supports now requires us to have a survey on each individual receiving services. You will need to complete a separate survey for each family member receiving services through ARCH. Information obtained in these surveys will remain confidential. Question Title * 1. Consumer Information First Name Last Name Age Primary Disability Address City State Zip Code Home Phone Question Title * 2. Parent/Guardian Information (residing at same address as consumer) Parent/Guardian Name Cell Phone Email Address Place of Employment Work Phone Relationship to Consumer Question Title * 3. Is the Parent/Guardian over 60 years of age? Yes No Question Title * 4. 2nd Contact Person or Parent Information- skip if not applicable Contact Name Relationship to Consumer Address City State Zip Code Home Phone Cell Phone Email Address Place of Employment Question Title * 5. How many adults (18 & older) reside in the household? 1 2 3 4 5 6 7 8 Question Title * 6. How many children (17 and under) reside in the household? 1 2 3 4 5 6 7 8 9 10 Question Title * 7. Are you receiving any services funded through the Missouri Department of Mental Health/Regional Office or Medicaid? Yes No Question Title * 8. How do you utilize your ARCH in-home residential care? Check all that apply. Brief breaks Socialization/outings Emergencies only Routine/scheduled Vacations Weekends Overnights Days Evenings Other, please specify Question Title * 9. Do you use any other in-home residential care programs besides ARCH? Yes No If yes, please indicate which program(s): Question Title * 10. Which services/supports does your family member with a developmental disability receive? Please check all that apply. In-Home Residential Care Adult Day Program Special School District Summer Camp Personal Care Assistance Nursing care Nanny care Sheltered Workshop Supportive Employment Competitive Employment Preschool or Day Care Before/after school care Adult Day Care Recreation Programs Other, please specify Question Title * 11. How many in-home residential care providers do you use? 1 2 3 4 5 6 7 8 Question Title * 12. How much do you pay your providers per hour? Question Title * 13. Who do you generally use as care providers? Check all that apply. Family Member (older than 16 residing outside the home) Friend Neighbor Church/synagogue member Teacher Other, please specify The following information is used to help us determine how many hours of care to assign your family. Question Title * 14. Does your family member with a developmental disability have any medical/health problems at the present time? Yes No If yes, please explain Question Title * 15. Does your family member with a developmental disability have behaviors that increase your need of in-home residential care? Yes No If yes, please explain Question Title * 16. Are there any health problems with the parent/guardian of this consumer? Yes No If yes, please explain Question Title * 17. Are there any problems or circumstances in your home at the present time that would increase your need for in-home residential care? Yes No If yes, please explain Question Title * 18. Do you consider the out-of-home placement for your family member with a developmental disability to be a critical need (meaning in the next 1-2 years)? Yes No Question Title * 19. If you have not used in-home residential care (ARCH services) in the past 1-3 years, please give reason(s) why: Unable to find a provider Saving for emergencies only Unable to afford care even with reimbursement from the program Unable/haven't completed paperwork to get reimbursed Other (please specify) Question Title * 20. What additional comments do you have for us? Question Title * 21. Name of person completing this survey: Submit