Residential Survey

Your Name*

First Last

Your Email*

Are you filling this survey out for yourself or another person you provide care for?*

Myself
A person I provide care for
Both myself and the person I provide care for

Person Completing the Survey*

Other Person Completing the Survey

What is the name of the person you provide care for?*

First Last

I understand that the information I will be asked to provide does not constitute a rental application, nor does it guarantee residency at any Sunflower Hill property. The information will be used for programmatic planning and to assess the level of support needed. I understand the information provided will be kept confidential.

Agreement*

AGREE - I understand the submission of this form is not an application and does not guarantee residency.
DISAGREE - I do not wish to continue with the survey (Stop filling out this form).

Please fill out the remainder of this survey for the person who is interested in Sunflower Hill residential communities.

Zip Code*

ZIP Code

Email

Date of Birth*

Gender*

Male
Female

Ethnicity

Other Ethnicity

Do you have an intellectual or developmental disability?*

Yes
No

What is your current living status?*

If not living on your own, have you started planning to live outside of your parent/caregiver's home?*

What type of residential community are you interested in?*

Select all that apply.

Independent Living (Residents live in private apartments or homes with access to common areas, managing their own day-to-day care and pursuing activities and social interactions of their own choosing. Independent residential units include kitchens for independent meal preparation and offer minimal supports, which allows individuals to live independently in the community. Residents bring their individualized and customized ILS or SLS supports and services. Each resident chooses their Service and Support provider(s). Residents may change their service provider and stay in their home.)
Supportive Living Example (Residents live in a group home or apartment community where live-in support services are offered. Supportive living communities are often staffed with counselors and other workers who help residents live on their own. Supportive residential units typically do not include a personal kitchen, and instead offer a community kitchen where residents have the option of preparing meals and snacks with the guidance of staff. Supportive living is for individuals who need more support and supervision than what is provided by Independent Living Skills support staff.)
Other

If other, please describe*

What type of unit are you interested in*

Select as many as appropriate.

One bedroom apartment
Studio/efficiency apartment
Private master bedroom and private bath but shared living and kitchen space
Two bedroom, two bathroom with a caregiver or roommate
Any of the above

Are you currently receiving developmental services through the Regional Center or State Medicaid Waiver program?*

Yes
No, have not applied to the Regional Center
No, was denied services
No, but pay for services privately

Please check all the supported living services you would like to receive.*

Select as many as apply.

Apartment Life Skills (Resident activities and services, general living skills)
Health & Wellness (Medical Appt, managing Health Needs)
Personal Finance Management (paying bills)
Nutrition & Exercise (Grocery shopping, Individualized Nutrition Plan and Exercise Groups)
Adult Life & Skills (Community involvement programs, enrichment classes & programs, educational programs)
Vocational Training, Placement and Retention
Meals (possible meal plan i.e. Breakfast & Dinner)
None of the above
Other

Other Desired Living Services

Check any activity that you currently enjoy now or would like to have the opportunity to learn or enjoy more often.*

Select as many as apply.

Other Desired Activities

I would like to receive the Sunflower Hill Newsletter.*

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Sunflower Hill Residential Survey