Interest Survey for Stepping Stone Communities' Integrated and Intentional Apartment Building
This interest survey is to be completed by the person with disabilities who has an interest in potentially living in a neuro-diverse apartment building in Littleton, Colorado. If the person with disability needs help filling it out, a family member or other support person can help. But the questions should be answered from the point of view of the future potential resident. This is NOT AN APPLICATION, just an interest survey so we can have a better idea of what you would like in a future housing option.
Potential future resident's name:
Name of person completing this survey (if not the potential future resident)
Person filling out this survey- What is your relationship to the potential future resident?
Self (potential future resident)
Parent of potential future resident
Sibling/family member of potential future resident
Direct Care Provider/Staff (non family member) of potential future resident
Resource Coordinator or Case Manager of potential future resident
Legal Guardian (Court Appointed) of potential future resident
1. What county do you currently live in?
2. What is your current living situation?
In my family home with parents/relatives
My own home by myself
My own home with a live-in caregiver
My own home with other roommates who do not have disabilities
My own home with other roommates who do have disabilties
PCA- Personal Care Alternative ("Group Home")
Assisted Living Residence/Nursing Home
3. Which of the following demographics do you feel best describes you?
Individual with an intellectual or developmental disability
Senior (age 60+)
4. How would you best describe your disability, if applicable? (check all that apply)
N/A- I do not have a disability
Attention Deficit/Hyperactive Disorder
Fetal Alcohol Spectrum Disorder
Mental Health Challenges
Physical Disability and use a mobility device
Post Traumatic Stress Disorder
Spinal Cord Injury
Traumatic Brain Injury
5. How old are you (the future potential resident)?
6. Select your current income and/or public benefit sources (check all that apply):
SSI- Supplemental Security income
SSDI- Social Security Disability Insurance
HCBS Medicaid Waiver Services
Supplemental Nutrition Assistance Program (SNAP- food assistance)
Housing Choice Voucher (HCV, once Section 8)
Temporary Assistance for Needy Families (TANF)
Low-income Energy Assistance Program (LEAP)
Special Needs Trust
Financial assistance from family or friends
Financial assistance from other community organizations
Earned income from work of less than $300/month
Earned income from work $300-$600/month
Earned income from work $600-$1200/month
Earned income over $1200/month
7. The maximum I could afford to pay in rent each month is:
8. Are you currently receiving Home and Community Based Services through a Waiver from your local CCB (Community Center Board)
Yes, I am receiving Waiver services
No, but I'm on the waiting list for Waiver services
No, I private pay for services
What are Waiver Services?
What is a CCB?
9. If yes, what Waiver services are you currently receiving?
Developmental Disabilities Waiver (DD)
Supported Living Services Waiver (SLS)
Elderly, Blind and Disabled Waiver (EBD)
Spinal Cord Injury Waiver (SCI)
Brain Injury Waiver (BI)
Community Mental Health Supports Waiver (CMHS)
10. How would you describe your support needs (check all that apply)?
I need at least 1:1 support at all times or at least line of sight
I need 24-hour direct support/supervision, but sharing staff is fine
I need overnight, awake staff
I need support for my daily routine due to physical disability
I need specialized support due to my medical needs
I need specialized support due to high behavioral support needs
Scheduled support throughout the day and someone nearby and on-call at night
I need daily support just to check in and help me with small stuff
Every few days, I need some help
I need very little support, just an occasional phone call check in
No support needed
11. Are you employed or do you participate in other meaningful daily activities?
I work in the community and get paid
I am actively seeking employment
I attend a day program
I attend a pre-vocational training program
I attend college classes or participate in a post-secondary program
I volunteer in my community
12. How many combined hours per week (average) are you typically out of your home working, volunteering, attending day program and/or other activities?
13. Do you feel like any of the following are barriers to you accessing your community (check all that apply)?
I cannot find transportation to activities of interest
I cannot find activities that I can participate in with natural supports (unpaid supports)
I cannot find the direct support staff I need to participate in activities of interest
I cannot find anything that interests me in my community
I cannot pay for the direct support staff I need to participate in activities
I cannot afford to participate in activities of interest
None. I access my community as much as I want to
14. What do you feel are the barriers to maintaining friendships?
I do not know where to go to meet potential friends
Too much anxiety to try and meet new people
Difficulty scheduling to meet with friends
Money to spend on outings
Transportation to my friends
Nothing. I see my friends as much as I want to!
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