MRC Housing Survey

Massachusetts Rehabilitation Commission
HOUSING SURVEY

You can GET US the survey by:

Using the on-line submission option in the form below
Mailing it to Steve Scarano, MRC, 27 Wormwood Street, Boston MA 02210-1606
Faxing it to Steve Scarano at (617) 727-1354

Completion of the survey will NOT place you on any waiting lists for housing. However, if you voluntarily provide us with your contact information at the end of the survey form, we will contact you when opportunities become available.

If you have any questions or need assistance completing the survey, please call Steve Scarano at (617) 204-3724.

Section 1:

What is your housing situation now? Check any of the responses below that apply to you:

Living alone

Living in a large or congregate arrangement

Living with my family

Living in a nursing facility or institution

Living with roommates

Homeless living in a shelter or motel

Living in a shared situation with 2-3 others

Homeless living temporarily with someone else

Other: Description:

Section 2:

Do you own your own home or condominium? Yes No

Section 3:

Do you rent an apartment? Yes No

If so, are you receiving any housing subsidy? Examples of subsidies include Section 8, public housing and subsidized housing developments in which you pay a percentage (such as 30%) of your income for rent. Yes No

Section 4:

Please indicate the range in which your income falls:

$10,000 or less

$10,001 - $15,000

$15,001 - $20,000

$20,001 - $25,000

$25,001 - $30,000

$30,001 or more

Section 5:

Below is a list of different types of housing options. Please order the list from your most preferred living arrangement to your least preferred living arrangement. Enter "1" next to your first choice, "2" next to your second choice and so on. Note: You should assume that you would have access to any necessary support services.

An apartment by myself alone.

A shared apartment of house with 3 or more roommates.

An apartment with my children.

An elderly/disabled housing complex.

An apartment with my spouse.

Living with a family that is able to provide support services.

An apartment with my parents.

Sober Housing.

An individual apartment grouped with other apartments sharing services.

Other...
Description:

A nursing facility or state hospital.

A shared apartment or house with 1 or 2 roommates.

Section 6:

Please describe your ideal housing situation:

Section 7:

Would you be interested in home ownership? Yes No

Section 8:

Do you need housing with access features such as ramps or accessible bath? Yes No

Section 9:

Where would you prefer to live? Anywhere in Massachusetts A specific region

Describe location:

Section 10:

In addition to housing, please check all of the support services listed below that you feel you would need to live more independently.

Assistance with personal care

Assistance with shopping

Assistance with budgeting and bill paying

Assistance organizing daily activities such as scheduling appointments

Assistance getting to know a new community or neighborhood

Assistance with housekeeping (cleaning, laundry)

Assistance with meal preparation

Someone always with me

Someone available in case of emergencies

Section 11:

If you need personal care assistance, which of the following would interest you (check all that apply):

I prefer to have my own PCAs

I prefer to have my own home health aides

I am willing to share my PCAs or pool PCA hours with neighbors or roommates

I would like on-site emergency PCA backup where I live

Section 12:

If you use support services or PCA, which method of service delivery do you prefer (select only your first choice):

I prefer to hire and/or manage my own PCA, case manager or other assistance

I want help to hire and/or manage my own PCA, case manager or other assistance

I want someone else to hire and manage my PCA, case manager or other assistance

Please provide the following voluntary information about yourself if you are comfortable doing so:

Section 13:

What is your age?

18 years or younger

19-21

22-34

35-50

51-60

61-75

76 or older

Section 14:

Please indicate your disability. Check any that apply.

ALS

Down's Syndrome

Parkinson's

Amputation

Environmental Sensitivity

Polio

Arthritis

Fibromyalgia

Spinal Cord Injury

Autism

Friedrichs Ataxia

Speech Impediment

Blind

Hard Of Hearing

Spina Bifida

Cerebral Palsy

Heart Disease

Stroke

Cancer

HIV/Aids

Traumatic Brain Injury

Chemical Dependency

Late Deafened

Visual Impairment

Chronic Fatigue

LD/ADD/HAD/ADHD

Other-Cognitive

COPD

Lupus

Other-Mental Health

Deaf

Muscular Dystrophy

Other-Neurological

Degenerative Disease

Mental Ret/Dev

Other-Physical

Dementia/Alzheimer's

Other-Sensory

Diabetes

Oral Deaf

Other:

Orthopedic

Section 15:

Are you a client of the Department of Mental Retardation? Yes No

Section 16:

Are you a client of the Department of Mental Health? Yes No

Section 17:

Please indicate who has completed this form.

Individual who has a disability

Parent of person with a disability

Case manager for consumer

Other:

We would appreciate your name and current phone number should we have further questions about your housing needs and to keep you informed of any housing opportunities that may arise.

First Name:

Last Name:

Phone:

Email:

Privacy Policy: Any information you provided will be kept confidential and used only to assist in the development of housing opportunities for people with disabilities.

Return to the official MRC website at www.mass.gov/mrc