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Applicant Questionnaire
Name of Applicant (*)
Invalid Input
Date
Invalid Input
I am motivated
Not True
Sometimes True
Often True
Always True
Invalid Input
I am reliable. I do what I say I will do.
Not True
Sometimes True
Often True
Always True
Invalid Input
I can take care of myself. I don’t sit back and wait for help.
Not True
Sometimes True
Often True
Always True
Invalid Input
I follow a daily schedule
Not True
Sometimes True
Often True
Always True
Invalid Input
I can stay home by myself
Not True
Sometimes True
Often True
Always True
Invalid Input
I can adjust to new situations. Change is easy for me.
Not True
Sometimes True
Often True
Always True
Invalid Input
I have one good friend or more.
Not True
Sometimes True
Often True
Always True
Invalid Input
I make good every day decisions.
Not True
Sometimes True
Often True
Always True
Invalid Input
I go to other people for help when I need it
Not True
Sometimes True
Often True
Always True
Invalid Input
I can react in an emergency. I don’t panic.
Not True
Sometimes True
Often True
Always True
Invalid Input
I often lose my temper.
Not True
Sometimes True
Often True
Always True
Invalid Input
I am nervous in new situations.
Not True
Sometimes True
Often True
Always True
Invalid Input
I think before I do things.
Not True
Sometimes True
Often True
Always True
Invalid Input
I am easily distracted. I find it difficult to concentrate.
Not True
Sometimes True
Often True
Always True
Invalid Input
I can follow a daily personal care routine
Not True
Sometimes True
Often True
Always True
Invalid Input
I do chores around the house.
Not True
Sometimes True
Often True
Always True
Invalid Input
I can go out in the community by myself.
Not True
Sometimes True
Often True
Always True
Invalid Input
I can do my own laundry.
Not True
Sometimes True
Often True
Always True
Invalid Input
I don’t involve myself in other people’s business
Not True
Sometimes True
Often True
Always True
Invalid Input
I want to live in my own apartment with a roommate.
Not True
Sometimes True
Often True
Always True
Invalid Input
I can take my own medication.
Not True
Sometimes True
Often True
Always True
Invalid Input
I can make my own breakfast or lunch.
Not True
Sometimes True
Often True
Always True
Invalid Input
Why do you want to live in your own apartment?
Invalid Input
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J-CHAI Application
Complete Application Procedures
J-CHAI Application Part 1
J-CHAI Application Part 2
J-CHAI Application Part 3
Applicant Questionnaire
Parent/Guardian Questionnaire
Confidential Applicant Recommendation Form
Authorization Form
Download Application (PDF format)
Download Recommendation Form (PDF format)
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