A. Personal Information
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:
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:
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 price of a subscription increases with time and after each new member joins. As of now, a subscription is $455,000 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?
H. Transition 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:
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.
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