Phone number of parent or guardian (XXX-XXX-XXXX) *
Your answer
Parent or guardian email *
Your answer
Sex of Resident *
Age of Resident *
Your answer
Can the resident be alone overnight? *
Please select all the activities the resident can engage in independently. *
Required
Can they engage in their daily routine with a minimum of 2 hours support daily? *
Do they want to live more independently? *
Can they cooperate with others? *
Does this resident have a behaviour safety plan? *
Your answer
Do they have an intellectual disability? *
Your answer
Do they have a physical disability? *
Your answer
Do they have any ADLs (Aids of daily living)? *
Your answer
Does the resident work or are they in school? *
When would the resident be ready to move in? *
MM
/
DD
/
YYYY
Is there any additional information you can share about your resident? *
Your answer
Why does the resident, or care taker want the resident to live in the Kind Minds House? *
Your answer
Why do you think they would be a good fit for the Kind Minds House? *
Your answer
Do they receive government funding? *
Are they interested in pooling funds with the other residents for shared support outside of the times offered by Kind Minds *
Do they require connection to an agent who can help them apply for government funding? *
I understand that Kind Minds will contact me using the email provided above to discuss the above mentioned residents eligibility for the Kind Minds House. *