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Health and Human Services 
  

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:
Other: Description:
Section 2:
Do you own your own home or condominium?    
Section 3:
Do you rent an apartment?    
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.    
Section 4:
Please indicate the range in which your income falls: 
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?    
Section 8:
Do you need housing with access features such as ramps or accessible bath?    
Section 9:
Where would you prefer to live?    

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.
Section 11:
If you need personal care assistance, which of the following would interest you (check all that apply):
Section 12:
If you use support services or PCA, which method of service delivery do you prefer (select only your first choice):
Please provide the following voluntary information about yourself if you are comfortable doing so:
Section 13:
What is your age?
Section 14:
Please indicate your disability. Check any that apply.
 Other:
Section 15:
Are you a client of the Department of Mental Retardation?    
Section 16:
Are you a client of the Department of Mental Health?    
Section 17:
Please indicate who has completed this form.
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.

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