Step 1

I am usually looking for resources for the following type of disability:

 Cerebral Palsy Brain Injury Deaf/HH Blind Spinal Cord Injury Autism/Aspbergers Other

Step 2

I am generally satisfied with the range of supportive services available for people with disabilities in the Lewis/Thurston/Mason County area.

 Strongly Agree Somewhat Agree Somewhat Disagree Strongly Disagree

Step 3

I (or my family member/friend) currently use the following services:

 Representative Payee Independent Living Services Respite Care Physical Therapy Occupational Therapy Communication Therapy Wheelchair Fitting/Repair Communication Device Fitting/Repair Other

Step 4

What is the farthest distance (round trip) you have to travel to access the services you are currently using?

 Less than 20 20-40 miles 40-60 miles 60-80 miles 80-100 miles More than 100 miles

Step 5

How often do you have to drive outside the Lewis/Thurston/Mason County area to access the services you are currently using?

 Once a week Once a month More than once a month More than twice a year Less than once a year

Step 6

If you were able to access the following services appropriate to your disability in the Lewis/Thurston/Mason County area, which services would you use?

 Representative Payee Independent Living Services Respite Care Physical Therapy Occupational Therapy Communication Therapy Wheelchair Fitting/Repair Communication Device Fitting/Repair Other:

Step 7

If I were going to use the services listed in Question 6, the services would be paid for with:

 Medicaid Coupon Medicare Private Insurance Private Pay I have no insurance coverage and I would need help to pay for these services.

Step 8

If the following opportunities were available at low cost or no cost in the Olympia/Lacey/Tumwater area, which ones would you be likely to use?

 Literacy Classes Support Group Exercise Class Relationship Class Craft Class Drama Group Art Class Bingo Science Class Cooking Class Counseling Computer Class Other:

Step 9

I really wish I had help to:

 Learn to live independently Meet new friends Find a ride to activities Learn to manage my money Take a vacation Read my mail Take a class Learn new skills Get a wheelchair that fits me well Other:

Step 10

Person completing this survey is a:

 Person with a disability Family member Guardian Friend Advocate Other Other

Step 11

I (or my family member/friend) live in:

 Thurston County Mason County Lewis County

Step 12

I (or my family member/friend) live in:

 Family Home Own Home/Apartment Adult Family Home Group Home Nursing Home Supported Living Friend or Caregiver’s Home

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