MY INDIVIDUAL EXPERIENCE SURVEY - RESIDENTIAL SUPPORT

You only need to fill out this if you live in an alternative family living or a group home. 

With NC DHHS Home and Community Based Settings (HCBS)

Section I: About you and your service

My Street Address
I have a guardian.
I have a power of attorney.
I am my own guardian.
I do not know if I have a guardian.

Section II: General Questions


No
Job
Money
Medicine
 
Home

Section III: Setting Owned or Controlled by a Provider

Home

You can learn more about your rights and responsibilities as a tenant and your landlord's responsibilities.

You only need to fill out this section if you live in alterative family living or a group home.


Signature Page

If you were asked to fill out the survey, please provide the survey number you were given.

If you have feedback or questions, please email: HCBSTransPlan@dhhs.nc.gov.