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Enhanced Services Survey
Enhanced Services Survey
Friend Name
Age
18-24
25-34
35-44
45-54
55-64
65+
Guardian / Representative Name (if any)
Phone
Email
Service Interests (Check all areas you are interested in)
Residential / Premium Services (respite care, supported living, specialized foster care)
Day & Employment Services (adult day programs, job training, placement)
Therapeutic & Health (therapy, behavioral or medical support)
Support Coordination (case management, transportation, advocacy)
Educational & Recreational (classes, social or community activities)
Preferred Services - Residential
In-Home Respite
Group Home Respite
Supported Living
Enhanced Group Home
Day & Employment
Adult Day Program
Community-Based Day Program
Pre-Vocational Training
Job Placement / Support
Therapeutic & Health
ABA Therapy
Speech
Physical
Behavioral / Mental Health
Medical / Nursing
Specialized (art, music, animal, etc.)
Support Coordination
Case Management
Family Support
Transportation
Service "Concierge" Support
Educational & Recreational
Art, Music, or Dance Classes
Technology Coaching (phone, iPad, social media)
Life Skills Coaching (budgeting, cooking, hygiene)
Community Outings & Day Trips
Staff-Facilitated Zoom / Video Calls
Karate or Fitness Classes
Other
If other, please specify
Highest Priority Service
- Select -
Preferred Services - Residential
Day & Employment
Therapeutic & Health
Support Coordination
Educational & Recreational
Second Highest Priority Service
- Select -
Preferred Services - Residential
Day & Employment
Therapeutic & Health
Support Coordination
Educational & Recreational
Third Highest Priority Service
- Select -
Preferred Services - Residential
Day & Employment
Therapeutic & Health
Support Coordination
Educational & Recreational
Submit Form
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