A. Personal Information B. Type of Disability
Please check all disabilities/special needs that apply
C. Level of Independence D. Behavior
1. Have you ever experienced issues with any of the following (check all that apply):
If Yes, describe in detail: E. Additional Information Please explain if any item is checked above: F. Expectations 1. Please describe why you would like to live in Clearwater Ranch Community: G. Supports and Documents 1. To be considered for residency in one of our supported-living homes, an individual must have sufficient resources available to provide appropriate levels of day-to-day in-home supports. All applicants must be Regional Center clients. Please detail what services you receive from your Regional Center: H. Transition 3. The transition to more independent living can be a very challenging time for an individual. The need for on-going family/advocate support is an important element to successful transition. Thus, Living Unlimited requires on-going family/advocate involvement to help the individual transition and succeed and to help the community develop. Please explain how you can volunteer to help? I. Additional Comments Please share below if there is anything else you would like us to know: J. How did you hear about us? K. Authorization & Representation
You, or your conservator, attest that the information provided in this questionnaire is true and complete, and understand and agree that providing false or inaccurate information is grounds for the elimination of residential consideration.
This Questionnaire was completed by: Clearwater Ranch Community is a community of Living Unlimited, a non-profit 501(c) (3) charitable organization whose mission is to establish and operate communities for adults with intellectual or developmental disabilities.
Where applicable, this questionnaire is subject to and contingent upon the prospective tenant(s) being approved by Living Unlimited.
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