CASS Housing Interest List Survey

Family Name:

Core Member Name:

First NameLast Name

Core Member Date of Birth:

MonthDayYear

Guardian Name (if applicable):

Our desired housing model:

Our preferred timeline to move into a CASS home:

Our preferred location:

We are flexible with our preferred location:

A little bit about the Core Member's personality:

Are they routine oriented? Are they a busy bee or do they enjoy to lounge? Do they enjoy socializing with others? Are they overstimulated easily? Are they outgoing or more of an introvert?

Is there anything specific the Core Member is looking for in a housemate?

Please describe the ideal housemate for the Core Member:

What types of personalities mesh well with the Core Member?

Does the Core Member have any pets that would be moving into the CASS home?

If yes, please tell us the type of pet:

Does the Core Member have any pet allergies?

Please list Core Member's pet allergies:

Core Member Hobbies and Interests

Is the Core Member currently employed?

How many hours a week does the Core Member work?

Does the Core Member receive SSI or SSDI?

If yes, what amount per month?

Is there anything else you'd like us to know?

Availability to connect:

Rows	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Morning
Afternoon
Evening

Comments on availability to connect:

What's your relationship to the Core Member?

Your Contact Information:

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Additional Contact Information:

Preferred method of contact: