"Housemate Survey Form" - Missouri

Housemate Survey Form is a legal document that was released by the Missouri Department of Mental Health - a government authority operating within Missouri.

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Download "Housemate Survey Form" - Missouri

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Housemate Survey
Name
Age
Date
These questions may help you find a housemate with interests similar to yours. If you
cannot answer the questions yourself, someone who knows you well can help. If someone
helps you, the following information should be supplied:
Assistance provided by
Phone
Relationship
E-mail
General Information
I would like to live in the following location? (If there is a specific location, list it.)
City
1.
Small Town
In the Country
I already know someone I’d like to have for a housemate. That person’s name is
2.
3.
I communicate by
My gender is:
I would rather live with people who are of the same
4.
Male
gender.
The gender of my housemate doesn’t matter to me.
Female
A housemate would need to
5.
know this about my lifestyle:
I could not live with someone who is:
I prefer to live with someone whose age is close to mine.
The age of my housemate doesn’t matter to me.
6.
Yes
If yes, what kind of pet?
7.
I would like a pet in the house.
If no, are certain pets ok (I.E. fish)
No
I smoke.
I could live with someone who smokes as long as they did it outside.
8.
I would not want to live with someone who smokes.
I do not care if my housemate smokes.
I have the following health/physical issues that may impact the person I live with :
9.
I have the following allergies (include food, medications or sensitivities [smells, perfumes,
10.
etc.] ):
Additional Comments:
Housemate Survey
Name
Age
Date
These questions may help you find a housemate with interests similar to yours. If you
cannot answer the questions yourself, someone who knows you well can help. If someone
helps you, the following information should be supplied:
Assistance provided by
Phone
Relationship
E-mail
General Information
I would like to live in the following location? (If there is a specific location, list it.)
City
1.
Small Town
In the Country
I already know someone I’d like to have for a housemate. That person’s name is
2.
3.
I communicate by
My gender is:
I would rather live with people who are of the same
4.
Male
gender.
The gender of my housemate doesn’t matter to me.
Female
A housemate would need to
5.
know this about my lifestyle:
I could not live with someone who is:
I prefer to live with someone whose age is close to mine.
The age of my housemate doesn’t matter to me.
6.
Yes
If yes, what kind of pet?
7.
I would like a pet in the house.
If no, are certain pets ok (I.E. fish)
No
I smoke.
I could live with someone who smokes as long as they did it outside.
8.
I would not want to live with someone who smokes.
I do not care if my housemate smokes.
I have the following health/physical issues that may impact the person I live with :
9.
I have the following allergies (include food, medications or sensitivities [smells, perfumes,
10.
etc.] ):
Additional Comments:
Additional Comments:
Personal Traits & Behaviors
Additional Comments:
Mark the words that describe you:
Friendly
Shy
Loud
1.
Happy
Sad
Quiet
I enjoy hugs from:
2.
I am very concerned about the
cleanliness of my home/housemate.
3.
Having a clean home/housemate is not
that important to me.
I will share household responsibilities
4.
with my housemate. The chores I prefer
to do are:
5.
When I get upset, I
6.
My feelings get hurt easily.
7.
I like to help others.
I like to share my belongings with
8.
others.
9.
I borrow things from others often.
I am bothered by profanity and
10.
cursing.
11.
I would want these rules in my home:
My temperature preference is:
Warm
12.
Cool
Don’t Care
Additional Comments:
Activities & Interests
1.
I enjoy playing video games.
I enjoy watching movies. If so, what type(s)
2.
(comedy, animation/Disney, scary, etc.)?
I enjoy watching television.
3.
If so, what shows?
I am bothered by scary or violent movies,
4.
television shows, or video games.
I like to listen to music. If so, what type?
5.
6.
I like to play music loudly.
I like to participate in sports.
7.
If so, what type(s)?
I like to play games. If so, what type?
8.
I enjoy spending time outdoors.
9.
If so, what outdoor activities?
10.
Other hobbies I enjoy are:
I usually stay at home during the day.
11.
I usually spend the day away from home
(Describe what you do.)
Additional Comments:
Additional Comments:
Eating Habits
1.
I can cook my own food.
2.
I am willing to cook for my housemate.
3.
I like to share food.
4.
I do not like to share food.
5.
I require a special diet. (Describe it):
Additional Comments:
Additional Comments:
Sleeping Habits
1. On week days (M-F), I generally like to wake up at
2. On week days, I like to be in bed by
3. On weekends, I generally like to wake up at
4. On weekends, I generally like to be in bed by
5.
I get up during the night.
6.
I snore.
7.
I like to take naps.
Additional Comments:
Additional Comments:
Socialization
1.
I enjoy having guests in my house:
Every day.
Once a week.
A couple of times a week.
I prefer not having a lot of guests.
I like to attend religious services.
2.
If so, what religion?
How often do you like to attend religious
activities?
I would like to spend time with my housemate.
3.
I would rather go out in the community for
activities than stay home.
4.
I would rather stay home than go out into the
community for activities.
5.
When I go out , I like to:
Additional Comments:
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