Personal Supports Application

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About Personal Supports

With Personal Supports Services, clients are able to receive truly personalized one-to-one assistance for a variety of needs and interests by a paid (and trained!) staffer, including those relating to participation in the community (during safer times), independent living skills development or enhancement, support with personal care items and help with academic needs or interests! We LOVE this program and truly believe that the possibilities are endless!

Application Follow-Up

After you finish the application, our team will review and will follow up with next steps or our admission decision. Please note that, due to the volume of inquiries, it may take us up to five business days to follow up, but we WILL follow up as soon as possible! Please click "NEXT" to begin!

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Please enter your first name.* This field is required.

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Please enter your last name.* This field is required.

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Please enter your phone number.* This field is required.

Area Code

Phone Number

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Thank you! Please enter your email address.* This field is required.

example@example.com

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Please enter the first name of the person who would be receiving services.* This field is required.

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{pleaseEnter56}, have you already completed our Quiz related to Personal Supports Services for {pleaseEnter5}?* This field is required.

YESNO

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Thank you! Because you have already completed the Quiz, we will use the information provided and only ask a few more questions.

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Personal Supports services are awarded by DDA in hourly increments per week. If accepted, how many hours of Personal Supports per week would {pleaseEnter5} want?* This field is required.

10 Hours Per Week

15 Hours Per Week

20 Hours Per Week

25 Hours Per Week

30 Hours Per Week

40 Hours Per Week

More than 40 Hours Per Week

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What City and County does {pleaseEnter5} live in?* This field is required.

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Does {pleaseEnter5} need or want help finding fun or interesting activities in the community?* This field is required.

YESNO

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Awesome, does {pleaseEnter5} need or want Staff assistance participating in activities in the community?* This field is required.

YESNO

13

Does {pleaseEnter5} want help learning any of the following independently living skills? Communication Skills, Cooking, Education Planning, Emergency and Safety Skills, Meal Preparation, Health, Housekeeping, Interpersonal/Social Skills, Knowledge of Community Resources, Money Management, Personal Appearance or Hygiene, or Transportation/Travel Training.* This field is required.

YESNO

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Does {pleaseEnter5} need prompts to manage personal care tasks such as bathing, dressing, eating or toileting?* This field is required.

YESNO

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Does {pleaseEnter5} want someone to enjoy hobby or leisure activities with?* This field is required.

YESNO

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Does {pleaseEnter5} want assistance with nutrition or physical fitness activities?* This field is required.

YESNO

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Does {pleaseEnter5} want help learning how to socialize with peers and others or does {pleaseEnter5} want to meet and socialize with new friends?* This field is required.

YESNO

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Due to the sector's staffing challenges, we do not believe that Personal Supports is appropriate for individuals who have CRITICAL staffing needs (i.e., the individual or his/her family would experience harm or the inability to work if staffing were not available). If {pleaseEnter5} were accepted into our Personal Supports Program, would a devastating impact occur to {pleaseEnter5} or to {pleaseEnter5}'s natural supports due to a staff absence or staff attrition?* This field is required.

YESNO

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Would {pleaseEnter5} experience substantial anxiety, depression, aggression, anger or other adverse emotion if a staffer left service abruptly?* This field is required.

YESNO

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Our staff are not permitted to administer medicine during service times. Does {pleaseEnter5} need to have medicine administered during the desired time of the Personal Supports Services?* This field is required.

YESNO

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Is {pleaseEnter5} able to self administer this medication? If so, is {pleaseEnter5} able to identify each medication by name and tell you the diagnosis the medication is related to without assistance?

YESNO

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The staff at United Community Supports are not permitted to drive clients (either in their own or in other vehicles) due to high insurance costs and other risks. Does {pleaseEnter5} require a staff to drive in connection with services?

YESNO

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Agency supported transportation costs for required Personal Supports travel are very limited. Does {pleaseEnter5} expect to need a great deal of financial support for Personal Supports related travel?

YESNO

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Does {pleaseEnter5} have behavioral challenges?* This field is required.

YESNO

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Does {pleaseEnter5} need to use a wheelchair?* This field is required.

YESNO

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Does {pleaseEnter5} have equipment to assist with transfers or is {pleaseEnter5} able to transfer independently?* This field is required.

YESNO

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Does {pleaseEnter5} live with family members?* This field is required.

YESNO

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Are {pleaseEnter5}'s family member(s) involved with her or his ongoing care?* This field is required.

YESNO

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Does {pleaseEnter5} have a legal guardian?* This field is required.

YESNO

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What is the name of the legal guardian?* This field is required.

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During COVID, we are providing virtual services or paying family members to serve as staff. Please select the service type that {pleaseEnter5} is interested in during COVID?* This field is required.

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In an effort to maximize stability and service continuity, we wish to continue to partner with family members after the pandemic in some capacity. Does {pleaseEnter5} have a family member who is wiling to serve a paid staffer (as either a primary or back-up staffer) after the pandemic?* This field is required.

YESNO

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To resume in-person services, do you require the in-person staff to be COVID vaccinated?

Yes

No

No Preference

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We participate in a Provider Workgroup that is working to elevating service delivery for all people. In connection with this, information about race/ethnicity is needed. Are you comfortable providing this information?

YESNO

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Please select your race below.

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

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What is your ethnicity?

Hispanic or Latino

Not Hispanic

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Is {pleaseEnter5} vaccinated?* This field is required.

Yes

No

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Does {pleaseEnter5} currently live with someone?* This field is required.

Yes

No

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Are all of the people that {pleaseEnter5} live with vaccinated?* This field is required.

Yes

No

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Is {pleaseEnter5} able and willing to wear a mask during services?* This field is required.

Yes

No

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Is {pleaseEnter5} willing to have services in-home only?* This field is required.

Yes

No

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There is data that suggests that current vaccines may not be effective for some people who take medications that reduce the strength of the body's immune system (called immunosuppressive medication) or who otherwise have compromised immune systems. Does the {pleaseEnter5} or anyone who lives with {pleaseEnter5} take immunosuppressive drugs OR does {pleaseEnter5} or anyone who lives with {pleaseEnter5} have a compromised immune system? For examples of immunosuppressant drugs, please go to the following link: https://www.healthline.com/health/immunosuppressant-drugs* This field is required.

Yes

No

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