Health and Human Services
State Online Services
Massachusetts Rehabilitation Commission
You can GET US the survey by:
option in the form below
it to Steve Scarano, MRC, 27 Wormwood Street, Boston MA 02210-1606
it to Steve Scarano at (617) 727-1354
Completion of the survey will
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.
What is your housing situation now? Check any of the responses below that apply to you:
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
Do you own your own home or condominium?
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.
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
Below is a list of different types of housing options. Please order the list from your
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.
An individual apartment grouped with other apartments sharing services.
A nursing facility or state hospital.
A shared apartment or house with 1 or 2 roommates.
Please describe your ideal housing situation:
Would you be interested in home ownership?
Do you need housing with access features such as ramps or accessible bath?
Where would you prefer to live?
Anywhere in Massachusetts
A specific region
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
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
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:
What is your age?
18 years or younger
76 or older
Please indicate your disability. Check any that apply.
Spinal Cord Injury
Hard Of Hearing
Traumatic Brain Injury
Are you a client of the Department of Mental Retardation?
Are you a client of the Department of Mental Health?
Please indicate who has completed this form.
Individual who has a disability
Parent of person with a disability
Case manager for consumer
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.
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© 2013 Commonwealth of Massachusetts