CH2 Survey

This page is designed to develop a basic understanding of your family's makeup.

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1. What type of disability does your loved one have? Also, please describe the severity on a scale of 1 through 5?

What type of disability does your loved one have? Also, please describe the severity on a scale of 1 through 5? Down's Syndrome

Autism

Cerebral Palsy

Other (please specify)

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2. What activities does your family find fulfilling?

What activities does your family find fulfilling? Movies

Museums

Skating

Athletics

Other (please specify)

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3. What organizations have you had a relationship with in the past or present?

What organizations have you had a relationship with in the past or present? Arc of Dallas

MetroCare

None

Other (please specify)

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4. What life skills has your loved one developed to a point of proficiency?

What life skills has your loved one developed to a point of proficiency? Cooking

Cleaning

Dressing

Managing Money

None

Other (please specify)

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5. What amount have you specifically budgeted for the care of your developmentally challenged loved one (ie, food, clothing, medical expense, schooling)?

What amount have you specifically budgeted for the care of your developmentally challenged loved one (ie, food, clothing, medical expense, schooling)? $0-$500

$500-$1000

Over $1000

Not Considered

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6. What is the maximum distance you are comfortable being away from your developmentally challenged loved one?

What is the maximum distance you are comfortable being away from your developmentally challenged loved one? Less than 5 miles

5-50 Miles

50-100 Miles

No Preference

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7. What steps have you taken to make your home safer for your developmentally challenged loved one?

What steps have you taken to make your home safer for your developmentally challenged loved one? Ramps

Restroom Renovations

AV Equipment

Signs/Reminders

Padlocks

Other (please specify)

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8. What types of public transportation have you utilized?

What types of public transportation have you utilized? DART

Cabs

Handicapped Access Busses

DART Rail

Other (please specify)

9. What is the MOST ESSENTIAL quality of a CareGiver?

What is the MOST ESSENTIAL quality of a CareGiver? Loving

Respectful

Educated

Clean Appearance

Age

Gender

Good Listener

Nurturing

Other (please specify)

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10. Please take a moment to tell the staff here at Claudy's House about your family.

Please take a moment to tell the staff here at Claudy's House about your family.

CH2
Exit this survey

1. General Information

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1. What type of disability does your loved one have? Also, please describe the severity on a scale of 1 through 5?

*
2. What activities does your family find fulfilling?

*
3. What organizations have you had a relationship with in the past or present?

*
4. What life skills has your loved one developed to a point of proficiency?

*
5. What amount have you specifically budgeted for the care of your developmentally challenged loved one (ie, food, clothing, medical expense, schooling)?

*
6. What is the maximum distance you are comfortable being away from your developmentally challenged loved one?

*
7. What steps have you taken to make your home safer for your developmentally challenged loved one?

*
8. What types of public transportation have you utilized?

9. What is the MOST ESSENTIAL quality of a CareGiver?

*
10. Please take a moment to tell the staff here at Claudy's House about your family.

CH2Exit this survey

1. General Information

*1. What type of disability does your loved one have? Also, please describe the severity on a scale of 1 through 5?

*2. What activities does your family find fulfilling?

*3. What organizations have you had a relationship with in the past or present?

*4. What life skills has your loved one developed to a point of proficiency?

*5. What amount have you specifically budgeted for the care of your developmentally challenged loved one (ie, food, clothing, medical expense, schooling)?

*6. What is the maximum distance you are comfortable being away from your developmentally challenged loved one?

*7. What steps have you taken to make your home safer for your developmentally challenged loved one?

*8. What types of public transportation have you utilized?

9. What is the MOST ESSENTIAL quality of a CareGiver?

*10. Please take a moment to tell the staff here at Claudy's House about your family.

CH2
Exit this survey

*
1. What type of disability does your loved one have? Also, please describe the severity on a scale of 1 through 5?

*
2. What activities does your family find fulfilling?

*
3. What organizations have you had a relationship with in the past or present?

*
4. What life skills has your loved one developed to a point of proficiency?

*
5. What amount have you specifically budgeted for the care of your developmentally challenged loved one (ie, food, clothing, medical expense, schooling)?

*
6. What is the maximum distance you are comfortable being away from your developmentally challenged loved one?

*
7. What steps have you taken to make your home safer for your developmentally challenged loved one?

*
8. What types of public transportation have you utilized?

*
10. Please take a moment to tell the staff here at Claudy's House about your family.