HCBDD Survey for Persons Served Question Title * 1. What do you like most about your life right now? Home: Work: Relationships: Health: Question Title * 2. What is a big concern you have right now? Home: Work: Relationships: Health: Question Title * 3. What would make your life better? Home: Work: Relationships: Health: Question Title * 4. What are your dreams for your life (living, working, relationships, friends)? Question Title * 5. What is your age? 14-22 23-50 51-65 over 65 Question Title * 6. With whom do you live? Alone With family/parents With friends With roommates With spouse/significant other Question Title * 7. With whom do you WANT TO live? Alone With family/parents With friends With roommates With spouse/significant other Question Title * 8. Where do you live? Own Home or Apartment Group Home Nursing Facility Other (please specify) Question Title * 9. Where do you WANT TO live? Own Home or Apartment Group Home Nursing Facility Other (please specify) Question Title * 10. Do you have a paid service provider who assists you in your home? Yes No If yes, who is your provider? Question Title * 11. How do you spend your day and your week? (Indicate all that apply. For options other than Christie Lane Industries and Stay at home, please indicate business, provider, or school name.) Christie Lane Industries Stay at home Job in the community Enclave Other Adult Day program Attend school Other Please specify business, provider, or school names Question Title * 12. How much time do you spend with each daytime activity? one day or less two days three days four days five days Christie Lane Industries Christie Lane Industries one day or less Christie Lane Industries two days Christie Lane Industries three days Christie Lane Industries four days Christie Lane Industries five days Stay at home Stay at home one day or less Stay at home two days Stay at home three days Stay at home four days Stay at home five days Job in the community Job in the community one day or less Job in the community two days Job in the community three days Job in the community four days Job in the community five days Enclave Enclave one day or less Enclave two days Enclave three days Enclave four days Enclave five days Other Adult Day program Other Adult Day program one day or less Other Adult Day program two days Other Adult Day program three days Other Adult Day program four days Other Adult Day program five days Attend school Attend school one day or less Attend school two days Attend school three days Attend school four days Attend school five days Other Other one day or less Other two days Other three days Other four days Other five days Question Title * 13. How would you like to spend your day and your week? (Indicate all that apply. For options other than Christie Lane Industries and Stay at home, please indicate business, provider, or school name.) Christie Lane Industries Stay at home Job in the community Enclave Other Adult Day program Attend school Other Please specify business, provider, or school names Done