Residential Interest Survey - Resident with Intellectual/Developmental Disability
This interest survey is to be completed by the person with disabilities who has an interest in potentially living at One Kin Roof. If the person with the disability needs help filling it out, a family member or other support person can help! The questions are directed at the person with disabilities, not the person helping them fill out the form. This is not an application to live at One Kin Roof, just a survey so we can have a better idea of what you would like in a housing option!
The person completing this survey is:
Self (Potential Future Resident)
Parent of potential future resident
Sibling or other relative of potential future resident
Legal Guardian (Court Appointed) of potential future resident
Support Coordinator or Service Provider of potential future resident
In what county do you currently live?
Other county in FL
Out of state
How old are you?
0 - 13
14 - 21
22 - 35
35 - 50
How would you best describe your disability? (check all that apply)
Mental health challenges
Other developmental disability
Physical disability and use a wheelchair
Traumatic Brain Injury
Where do you currently live?
In my family home with parents/relatives
My own home with other roommates who have disabilities
My own home with roommates who do not have disabilities
My own home by myself
Foster or Adult Companion Home
Assisted-Living or Nursing Home
Select your current income and public benefits:
SSI - Supplemental Security Income
SSDI - Social Security Disability Insurance
Medicaid or "waiver" services
Special Needs Trust
SNAP (food stamps)
Housing Choice Voucher
Earned income from work of less than $300 a month
Earned income from work $300 - $600 a month
Earned income from work $600 - $1200 a month
Earned income from work over $1200 a month
Financial assistance from family
Financial assistance from friends
Financial assistance from other community organization
Are you currently receiving support services through the Agency for Persons with Disabilities (APD)?
No, I'm on the waiting list
No, I pay for services privately
What is the Agency for Persons with Disabilities?
How do you best communicate?
I can tell you what is on my mind in full sentances
I have a limited set of words I use
I use sign language or finger spelling
I use gestures or body language
I use a communication device independently
I use a communication device with help or prompts
How would you describe your support needs?
I need at least 1:1 support at all times or at least line of sight
I need 24-hour direct support and supervision, but sharing staff is fine
I need overnight awake staff
Scheduled support staff throughout day, and someone nearby and on-call at night
I need daily on-site support just to check in and help me with small stuff
Every few days I need some help
I need support for my daily routine due to physical disability
I need specialized support due to medical needs
Are you employed or participate in other meaningful daily activities?
I work in the community and get paid
I work at an ADT (Adult Day Training) and get paid
I am actively seeking employment
No, I am not interested in employment
I attend a day program
I am often bored because of the lack of opportunities
I create my own schedule and do things I like to do
How many combined hours per week (average) do you work, volunteer and/or go to a day program?
1 - 7
8 - 16
17 - 24
25 - 33
34 - 41
42 - 50
50 - 59
What do you feel are the barriers to friendship and access to your community:
Money to spend on outings
Lack of social skills to maintain friendships
Difficulty scheduling to meet with friends
Too much anxiety to try and meet new people
Cannot find activities that meet one’s interests to meet friends
Cannot find activities that one can participate in with natural supports (unpaid support)
Cannot find direct support staff I need to participate in interested activities
I don't always want my family to supervise, so I rather not go
I cannot pay for direct support staff I need to participate in interested activities
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