Texas Olmstead Story Form 2023

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

ADAPT of Texas and Personal Attendant Coalition of Texas (PACT) want to collect stories of individuals at risk of becoming or/are institutionalized due to lack of personal attendant services and other barriers. Supporting the Fifth Core Service of preventing and assisting people with disabilities to move out of nursing homes and other institutions is key to the independence for our disability community. Older Texans also want to age in place and not be institutionalized in nursing facilities. Please help us collect these stories by sharing this survey with people who may be interested in sharing their experiences with us.

If you have any questions or would like any other assistance, please contact Cathy Cranston, flacacata@aol.com or Nancy Crowther, ncrowther21@gmail.com

Email *

Name:

Address:

Phone:

E-mail address:

Checklist of Potential Reasons for one going in or at risk of going into or coming out of a Nursing Home/ Institution:

Lack of Attendant Services

Lack of Housing

Can not find an Attendant/ Direct Support Professional/ Caregiver

Attendant leaving job for job that pays more.

Worker leaves without notice.

Other Explain:

Tell us what caused you to move into an institution/ nursing home (NH)

Tell us what is putting you at risk of living in an institution/ NH

Tell us what is keeping you from being able to move out of the NH.

Please describe how it happened, who was involved, why and when your civil rights were violated. It is alright to have someone else assist you in writing your story.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms