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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
Please check all disabilities/special needs that apply
C. Level of Independence
1. Please check the level of care that best fits your needs:
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?
E. Additional Information
Select all that apply:
F. Expectations
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
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.
I. Additional Comments
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.

Thanks for submitting!

We will respond to you shortly.

Thank you for your interest!

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