Apply 2 | CRC

1. Please check the level of care that best fits your needs:

Requires limited care and supervision. Can care for self. No behavior problems. Will thrive in home like environment.

Requires regular care, supervision, and incidental training needs. Has some self-care skills and needs modest assistance with activities of daily living. No major behavior problems, but may show mild behaviors (teasing, screaming, resistive) or mild non-compliance. Will thrive in home like environment.

Requires significant care, supervision, and ongoing training. Has significant deficits in self-help skills, and/or some limitations in physical coordination and mobility, and/or disruptive behavior.

Requires constant care, supervision, and professionally supervised training. Has major deficits in self-help skills, and/or severe impairment in physical coordination and mobility, and/or severely disruptive or self-injurious behavior. Provide clarifying comments, if desired:

2. Purchasing a subscription in CRC assures a residential space for the candidate resident. (with rent payment commensurate with SSI/SSDI income) The cost of subscription increases with time. As of February 2019, subscriptions are $355,000 and up. Pricing is subject to change. Is this price within your budget?

Yes

No

2. Is there a court approved conservatorship in place for this candidate resident?

Yes

No

3. Do you currently have a Special Needs Trust?

Yes

No

4. As we move forward in this assessment process, we will request that you share some of your child’s most recent information such as their most recent IEP, current IPP, and limited medical information. Are you willing to provide this information at the appropriate time?

Yes

No

1. Timing of possible transition. I can imagine my child transitioning from home to Clearwater Ranch:

2. To ensure a spot for my child, I would consider purchasing a place before my child is actually ready to transition, and I understand that CRC will rent it out until the house is ready to be tenanted.

Yes

No

Maybe

Questionnaire

This Questionnaire is for initial screening purposes only and does not guarantee the candidate will be offered a subscription. The questions and the use of "you" in the questions refer to the individual with special needs.

A. Personal Information

B. Type of Disability

C. Level of Independence

D. Behavior

E. Additional Information

F. Expectations

G. Supports and Documents

H. Transition

I. Additional Comments

J. How did you hear about us?

K. Authorization & Representation

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