Participation Lodge and Community Services Community Home Feasibility Survey

Participation Lodge and Community Services Grey Bruce is a non-profit organization that provides support to individuals with physical and developmental disabilities ages 16-65. Participation Lodge believes in inclusion and individualized support for all members being supported.

Participation Lodge has been approached to do a study to build family style homes in the community, which would support 4-5 individuals each. We’re asking you to please take 5 minutes to complete this survey by AUGUST 20/04, as your input is highly important in determining the feasibility of building a community home in the region. Your participation is requested as it could benefit yourself or perhaps a loved one who would benefit from this type of service.

All information collected in this survey is confidential and will be used solely for the Study and not for any other purpose.

START HERE
Send to:
Town or City in which you live.
Municipality in which you live.
Do you know of an individual who would benefit from this type of service provision?
If you anwered NO fill in section B the "Indirect" affects of this service and section C.

If you answered YES fill in section A the "Direct" affects of this service and section C.
SECTION A
If Yes, what Gender?
What is the age of this person?
Is the person...? Select item from list.
If there are more than two special needs describe these briefly.
What type of service are they currently receiving?
Is this person currently residing in a nursing home? If Yes, complete the following two questions.
Name of nursing home
Original town of residency
When would the person require service?
Level of support required? If other explain below.
Type of support required.
Type of Support Requested Indicate below
Preferred accommodation

(Check as many as apply.)
 Group Home
Apartment
In home with support
Institution (i.e. Cedar Springs)
Large Group Home
Other (If other explain below.)
Other type of accommodation.
Other requested services

(Check as many as apply.)
 Day Program
Respite
Education/Employment
Counseling
Other (If other explain below.)
Other type of services.
If this person is living with family members indicate the age category of the caregivers.
SECTION B
Do you feel there is demand for this service in this area? (specify where)
Do you have any issues with building a community home in this area? (explain)
Do you know of any other Community homes in this area?
SECTION C
Do you have any questions, suggestions or concerns about this type of venture?
   

When you submit this form you will be required to confirm that you wish an email to be sent from your computer. We do not retain/store email addresses from these submissions.

Note: To submit this form you must have an email service such as Outlook installed on your computer and a valid email address.