2010 Waiting List Survey Update

Answer questions as they relate to you. For most answers, check the boxes most applicable to you or fill in the blanks. Please contact Amy Berry, program director, with any questions at 816-836-3462.

General Information and Survey Questions

1.	Name of person in need of residential services:

Address:

3.	City/State/Zip Code:

County

	Jackson
	Other:

5.	Phone number:

Gender:

	Male
	Female

7.	Date of Birth:

Age:

9.	Guardian Status:

	Competent (self)
	Family Member
	Public Administrator

10.	Ethnicity:

	Caucasian
	African American
	Native American
	Hispanic
	Other:

11.	Diagnosis:

	Profound Mental Retardation
	Severe Mental Retardation
	Moderate Mental Retardation
	Mild Mental Retardation
	Borderline Mental Retardation
	Developmentally Delayed
	Other:

12.	Other Disabilities and Conditions:

	(Select all that apply.)
	Hearing impairment
	Vision impairment
	Non-verbal
	Seizure
	Cerebral Palsy
	Down Syndrome
	Autistic
	Secondary Diagnosis of Mental Illness
	Mechanical Supports Used for Ambulation (wheelchair, crutches, etc.)
	Other:

13.	Is a barrier free home needed?

	Yes
	No

14.	Is this person presently living at home with family?

	Yes
	No

15.	Is there an immediate need for services?

	Yes
	No

16.	If no, what year?

17.	Is he/she eligible for services or receiving assistance from the Kansas City Regional office or other regional center (Department of Mental Health)?

	Yes
	No

18.	Is he/she receiving financial assistance from SS or SSI

	Yes
	No

19.	He/she attends:

	(Select all that apply.)
	Day program
	School
	Is Employed
	Is Retired

20.	Support service desired:

	(Select all that apply.)
	Carriage House - A home for up to 6 women. A residence manager and support staff provides services on a continual basis.
	Main Street House - A home for up to 5 women. A residence manager and support staff provides services on a continual basis.
	Manor House - A home for up to 6 men. A residence manager and support staff provides services on a continual basis.
	Nolen Manor - A home for up to 8 men and women. A live-in staff, residence manager and support staff provides services on a continual basis.
	Special Neighbors Apartments - This complex contains 12 studio apartments, each with a full bath and kitchen. While there is a residence manager, support staff and a live-in staff, on the premises, each person must be capable of spending time alone at home or in the community.
	Marlow Place - A three unit complex next to Special Neighbors Apartments. Each unit has 2 bedrooms, a kitchen and full bath. Support is based on individual need.
	Individualized Supported Living/Community Integration - Individuals are provided support in their own homes throughout the Eastern Jackson County. Services provided vary based on the needs and capabilities of the individuals.
	White Oaks - A specialized care home for up to 12 individuals with severe, multiple handicaps and developmental disabilities. Due to the intense needs of the program participants, the residence manager, assistant residence manager, and staff provide around the clock support.

21.	List name of day program, school or employer:

	(Provide up to three responses.)

22.	Support service desired:

	(Select all that apply.)
	Carriage House - A home for up to 6 women. A residence manager and support staff provides services on a continual basis.
	Main Street House - A home for up to 5 women. A residence manager and support staff provides services on a continual basis.
	Manor House - A home for up to 6 men. A residence manager and support staff provides services on a continual basis.
	Nolen Manor - A home for up to 8 men and women. A live-in staff, residence manager and support staff provides services on a continual basis.
	Special Neighbors Apartments - This complex contains 12 studio apartments, each with a full bath and kitchen. While there is a residence manager, support staff and a live-in staff, on the premises, each person must be capable of spending time alone at home or in the community.
	White Oaks - A specialized care home for up to 12 individuals with severe, multiple handicaps and developmental disabilities. Due to the intense needs of the program participants, the residence manager, assistant residence manager, and staff provide around the clock support.
	Marlow Place - A three unit complex next to Special Neighbors Apartments. Each unit has 2 bedrooms, a kitchen and full bath. Support is based on individual need.
	Individualized Supported Living/Community Integration - Individuals are provided support in their own homes throughout the Eastern Jackson County. Services provided vary based on the needs and capabilities of the individuals.

23.	Name of person completing survey:

24.	Would you like to be on Special Neighbors's mailing list?

	Yes
	No

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