Residential Support Services Application


Date *
Name *
Gender *
Do you have any children *
Do you have strong family relationships? *
Do you have long term friends? *
Do you have limited contact with others? *
Do you prefer to be alone? *
Are you a social person? *
Do you take your medication accurately? *
Are you diabetic? *
Do you follow a specific diet? *
Are you able to complete your own personal cares *
Are you able to dress independently? *
Are you able to toilet independently? *
Do you need prompts for hygiene cares? *
Do you adhere to doctor's orders? *
Are you able to transfer independently? *
Do you have allergies? *
Are you even-tempered under pressure? *
Do you set high standards for yourself? *
Do you get frustrated easily? *
Are you verbally abusive to others? *
Are you physically abusive to others? *
Do you have a history of physical violence? *
Are you able to process received information? *
Do you listen to others? *
Are your thoughts organized? *
Do you feel you communicate effectively? *
Do you prefer verbal communication? *
Do you prefer written communication? *
Life Management
Are you organized? *
Do you use structure in your life? *
Do you adhere to a schedule? *
Are you able to schedule appointments? *
Do you attend doctor appointments independently? *
Do you need assistance with transportation? *
Can you shop for personal needs independently? *
Are you a morning person? *
Are you responsible for your finances? *
Personal Growth
Do you have goals? *
Are you motivated to achieve your goals? *
Do you mind living with males and females? *
Do you mind who does your cares? *
Do you have any pets? *
Do you need bedroom furniture? *
Section 9