A. Personal Information Candidate's Full Name Street City/State/Zip Parent/Conservator/Other Relationship Email Phone B. Type of Disability
Please check all disabilities/special needs that apply
C. Level of Independence
1. Please check the level of care that best fits your needs:
2. Describe any significant medical issues that may affect daily living. (Examples: allergy, uncontrolled seizures, etc.) D. Behavior
1. Have you ever experienced issues with any of the following (check all that apply):
2. Have you had any behavioral issues resulting in injury requiring medical care or police involvement within the last 3 years?
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:
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?
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:
2. Is there a court approved conservatorship in place for this candidate resident?
3. Do you currently have a Special Needs Trust?
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?
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.
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: Name: 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. Submit