Cohome Questionnaire

Thank you for your interest in Cohome. We are so excited to meet you and learn more about your goals and interests. Cohome creates intentional independent living spaces and facilitates engaging, inclusive programs. 

The decision to enroll in any Cohome program is significant. Our application process reflects this. Acceptance decisions are made based on the “goodness of fit” between the applicant and the Cohome program. When completing the “Independent Living Skills” section, please select the answer that best reflects an applicant’s abilities; there are no “right” answers. Simply, this application helps us learn more about an applicant. Cohome welcomes applicants of all abilities. 

Please complete this application and submit it to Cohome with the additional materials listed below. Once an application has been received and reviewed you will be invited for a meeting with Cohome staff. Cohome operates its housing in compliance with federal and state housing laws.

Sign in to Google to save your progress. Learn more
Email *
Applicant Name *
Date of Birth *
MM
/
DD
/
YYYY
Mailing Address *
Email Address *
Telephone Number *
Parent/Guardian/Alternate Contact's Full Name *
Phone Number *
Email Address *
How did you hear about Cohome? *
Required
Type of Disability (check all that apply) *
Required
Please describe your disability. *
Personal History
Select all of the following statements that are true.
 *
Required
If you answered "yes" to the above, please describe.
Have you ever lived independently (i.e. outside your childhood home such as, college, residential program, or other)?
 *
Required
Does the applicant have any history of behavioral or emotional difficulties (aggressiveness, self-harm, threatening, depression, violent ideation)?
 *
Required
Are you currently registered with The New Jersey Division of Developmental Disabilities (NJ DDD)?
 *
Required
If you answered "Yes" to the above, what is your NJ CAT Tier Assignment? *
Required
If you have an acuity, please describe. 
Do you have a budget from DDD?  *
If yes, which program?  *
Do you currently get support services? 
Clear selection
What agency, company, or private individual(s) provide these services? Please provide name and phone number. 
How are these services paid for? 
How many hours of support per week do you, or do you plan to, receive support from this provider? 
Clear selection
Do you take medications?  *
If yes, please list medication names, how often you take them, and reason for taking them. 
Do you need nursing or medical care on a daily basis?  *
If you answered yes to the previous question, please explain. 

Please select the last level of schooling matriculated.

 *
Required

Please select the option that best describes your meaningful engagement activities (if “other,” describe any activities you participate in outside of our home (i.e. church, club, supported employment, etc).

 *
Required
Do you drive?  *
If you answered yes to the previous question, do you own a car? 
Clear selection
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Cohome, Inc.. Report Abuse
Google Forms