The CCHI: Interest Form

Parents/Guardian First Name

Parents/Guardian Last Name

Address

Street Address

City

State

Country

Postal Code

OTHER PARENTS/GUARDIAN ADDRESS WHERE APPLICABLE

PARENTS/GUARDIAN PHONE NUMBERS *

PLEASE LIST GUARDIAN EMAIL *

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AGE OF CCHI MEMBER

PLEASE LIST GENDER

IF YOU ARE REACHING OUT TO US REGARDING HOUSING, WHEN ARE YOU LOOKING TO MOVE INTO A NEW LIVING ARRANGEMENT?

WHAT IS THE DIAGNOSIS

DO YOU NEED HELP WITH MEAL PREPARATION?

Yes

No

Rarely

Other

ARE YOU INTERESTED IN HAVING MEALS PROVIDED FOR YOU/EATING GROUP MEALS?

Yes

No

Sometimes

Other

CCHI’S BUILDING IS A CO-OP WITH FAMILIES PURCHASING SHARES. ARE YOU ABLE TO DO THIS? THE COST RUNS BETWEEN 125K–250K.

Yes

No

Maybe

Other

THIS COMMUNITY WILL REQUIRE MONTHLY FEES TO COVER UTILITIES, TAXES, INSURANCE, 24/7 FRONT DESK, AND AN OVERNIGHT RA.

Yes, I am able to pay $950-$1600 per month to cover these fee.

No, I am unable to pay $950-$1600 per month to cover these fees.

I am not sure?

WHAT IS YOUR LEVEL OF SUPPORT NEEDS?

Minimal Supports(Daily Check Ins)

Medium Support(Mornings, Evenings, Some Life Skill Assistance)

High Need Support(24/7)

PLEASE DESCRIBE YOUR SUPPORT NEEDS:

PLEASE DESCRIBE BEHAVIOR ISSUES YOU EXPERIENCE:

ARE YOU ABLE TO BE INDEPENDENT FOR SEVERAL HOURS A DAY?

CLICK HERE NOW TO BECOME A CCHI MEMBER!

CCHI REQUIRES FAMILIES INVOLVEMENT REGARDING BUILDING RELATIONSHIPS WITH ONE ANOTHER WHICH HELPS TO CREATE OUR SENSE OF COMMUNITY, AS WELL AS FUNDRAISING AND PROGRAMMING. ARE YOU ABLE TO COMMIT TO THIS AT LEAST 5 HOURS A MONTH?

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