Technical Assistance Parent Needs Survey

Hello, We are sending you this electronic survey on behalf of the Association for Special Children and Families. We would like to request that you complete the following questions that will require only a few minutes of your time. We ask for this information to be able to better serve you and others with special needs children. Thanking you in advance for your honesty and time. We look forward to continued support on behalf of your special needs child(ren).

If you should have any questions, please feel free to contact our office @ 973-728-8744 or 973-728-0999 or via e-mail @ ascfamily@hotmail.com

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1. So we can identify the area you are reporting from and language needs, please enter the following:

So we can identify the area you are reporting from and language needs, please enter the following: City / Town
Zip
County
Language Spoken
Name (optional)
Phone Number (optional)

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2. Marital Status:

	Single	Married	Prefer not to answer
Marital Status:	*Marital Status: Marital Status: Single	Marital Status: Married	Marital Status: Prefer not to answer

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3. Household Statistics

	Receiving AFDC/Cash Assistance	Income below $ 17,050	Income between $ 17,051 and $ 25,574	Income between $ 25,575 and $ 34,099	Income above $ 34,100	Prefer not to answer
Total Household Income:	*Household Statistics Total Household Income: Receiving AFDC/Cash Assistance	Total Household Income: Income below $ 17,050	Total Household Income: Income between $ 17,051 and $ 25,574	Total Household Income: Income between $ 25,575 and $ 34,099	Total Household Income: Income above $ 34,100	Total Household Income: Prefer not to answer

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4. Housing Status:

	(indicate where you live)	Number of individuals living in my household	# of generations in the home
I	Housing Status: I (indicate where you live)	Number of individuals living in my household	# of generations in the home

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5. My current employment status is: (Please select one)

My current employment status is: (Please select one) Employed full time

Employed part time

Home full time (by choice)

Home full time (looking for employment)

Disabled (not working)

Disabled (working part time)

Disabled (working full time)

Retired

Other (please specify)

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6. What is your relationship to child(ren)/young adult(s) with disabilities ? (please check all that apply)

What is your relationship to child(ren)/young adult(s) with disabilities ? (please check all that apply) Self

Parent

Adoptive Parent

Guardian

Family Member

Foster Parent

Concerned Individual

Employee of school district (teacher, aide, CST, therapist, administrator, other)

Professional in Health Care field

Professional in Child Care field

Professional in Education field

Professional in Social Services field

Professional in Advocacy field

Other (please specify)

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7. I have had the following experiences (Please select all that apply)

I have had the following experiences (Please select all that apply) Parenting a child(ren) with special needs (physical, developmental, behavioral)

Living in a family where English is not the only language spoken

Single parenting / having been separated or divorced

Military deployment (self or spouse)

Parenting while your spouse / partner experienced mental health issues

Parenting while your spouse / partner had been incarcerated

Being a parent with a disability

Being a teen parent

None of the above (check ONLY IF you have NOT chosen one of the above answers)

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8. Tell us a little about the child(ren)/young adult(s) with a disability: (PROFESSIONALS please indicate N/A for this question and provide your input on the next question).

	Not Applicable	Male	Female	0-3	4-5	6-12	13-18	19-26	Adult	Caucasian	African American	Native American	Hispanic	Asian	Other
Person # 1	*Tell us a little about the child(ren)/young adult(s) with a disability: (PROFESSIONALS please indicate N/A for this question and provide your input on the next question). Person # 1 Not Applicable	Person # 1 Male	Person # 1 Female	Person # 1 0-3	Person # 1 4-5	Person # 1 6-12	Person # 1 13-18	Person # 1 19-26	Person # 1 Adult	Person # 1 Caucasian	Person # 1 African American	Person # 1 Native American	Person # 1 Hispanic	Person # 1 Asian	Person # 1 Other
Person # 2	Person # 2 Not Applicable	Person # 2 Male	Person # 2 Female	Person # 2 0-3	Person # 2 4-5	Person # 2 6-12	Person # 2 13-18	Person # 2 19-26	Person # 2 Adult	Person # 2 Caucasian	Person # 2 African American	Person # 2 Native American	Person # 2 Hispanic	Person # 2 Asian	Person # 2 Other
Person # 3	Person # 3 Not Applicable	Person # 3 Male	Person # 3 Female	Person # 3 0-3	Person # 3 4-5	Person # 3 6-12	Person # 3 13-18	Person # 3 19-26	Person # 3 Adult	Person # 3 Caucasian	Person # 3 African American	Person # 3 Native American	Person # 3 Hispanic	Person # 3 Asian	Person # 3 Other
Person # 4	Person # 4 Not Applicable	Person # 4 Male	Person # 4 Female	Person # 4 0-3	Person # 4 4-5	Person # 4 6-12	Person # 4 13-18	Person # 4 19-26	Person # 4 Adult	Person # 4 Caucasian	Person # 4 African American	Person # 4 Native American	Person # 4 Hispanic	Person # 4 Asian	Person # 4 Other
Person # 5	Person # 5 Not Applicable	Person # 5 Male	Person # 5 Female	Person # 5 0-3	Person # 5 4-5	Person # 5 6-12	Person # 5 13-18	Person # 5 19-26	Person # 5 Adult	Person # 5 Caucasian	Person # 5 African American	Person # 5 Native American	Person # 5 Hispanic	Person # 5 Asian	Person # 5 Other

9. PROFESSIONALS ONLY- Tell us a little about the child(ren)/young adult(s) with a disability:

	RESPONSE	NUMBER SERVED
Male	PROFESSIONALS ONLY- Tell us a little about the child(ren)/young adult(s) with a disability: Male RESPONSE	NUMBER SERVED
Female	Female RESPONSE	NUMBER SERVED
Age 0-3	Age 0-3 RESPONSE	NUMBER SERVED
Age 4-5	Age 4-5 RESPONSE	NUMBER SERVED
Age 6-12	Age 6-12 RESPONSE	NUMBER SERVED
Age 13 - 18	Age 13 - 18 RESPONSE	NUMBER SERVED
Age 19 - 26	Age 19 - 26 RESPONSE	NUMBER SERVED
Adult	Adult RESPONSE	NUMBER SERVED
Caucasian	Caucasian RESPONSE	NUMBER SERVED
African American	African American RESPONSE	NUMBER SERVED
Native American	Native American RESPONSE	NUMBER SERVED
Hispanic	Hispanic RESPONSE	NUMBER SERVED
Asian	Asian RESPONSE	NUMBER SERVED
Other	Other RESPONSE	NUMBER SERVED

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10. Please choose the disability for each child(ren)/young adult(s) listed above. (PROFESSIONALS please indicate N/A for each person in this question and provide your input on the next question).

	Disability
Child # 1's Disability	Please choose the disability for each child(ren)/young adult(s) listed above. (PROFESSIONALS please indicate N/A for each person in this question and provide your input on the next question). Child # 1's Disability Disability
Child # 2's Disability	Child # 2's Disability Disability
Child # 3's Disability	Child # 3's Disability Disability
Child # 4's Disability	Child # 4's Disability Disability
Child # 5's Disability	Child # 5's Disability Disability

11. PROFESSIONALS ONLY: Please choose the disability for each child(ren)/young adult(s) listed above.

	Disability	# Served
Type of Disability Group	PROFESSIONALS ONLY: Please choose the disability for each child(ren)/young adult(s) listed above. Type of Disability Group Disability	# Served
Type of Disability Group	Type of Disability Group Disability	# Served
Type of Disability Group	Type of Disability Group Disability	# Served
Type of Disability Group	Type of Disability Group Disability	# Served
Type of Disability Group	Type of Disability Group Disability	# Served

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12. PARENTING ISSUES: Please rate the importance for each of the following parenting needs:

	1 Very Important	2 Important	3 Not Important	4 Not Applicable
Parenting Skills Trainings	*PARENTING ISSUES: Please rate the importance for each of the following parenting needs: Parenting Skills Trainings 1 Very Important	Parenting Skills Trainings 2 Important	Parenting Skills Trainings 3 Not Important	Parenting Skills Trainings 4 Not Applicable
Trainings / Workshops	Trainings / Workshops 1 Very Important	Trainings / Workshops 2 Important	Trainings / Workshops 3 Not Important	Trainings / Workshops 4 Not Applicable
Parent Support Groups (facilitated by professional)	Parent Support Groups (facilitated by professional) 1 Very Important	Parent Support Groups (facilitated by professional) 2 Important	Parent Support Groups (facilitated by professional) 3 Not Important	Parent Support Groups (facilitated by professional) 4 Not Applicable
Parent to Parent Support Groups (facilitated by peer)	Parent to Parent Support Groups (facilitated by peer) 1 Very Important	Parent to Parent Support Groups (facilitated by peer) 2 Important	Parent to Parent Support Groups (facilitated by peer) 3 Not Important	Parent to Parent Support Groups (facilitated by peer) 4 Not Applicable
Individual Support by Staff	Individual Support by Staff 1 Very Important	Individual Support by Staff 2 Important	Individual Support by Staff 3 Not Important	Individual Support by Staff 4 Not Applicable
Community Acceptance	Community Acceptance 1 Very Important	Community Acceptance 2 Important	Community Acceptance 3 Not Important	Community Acceptance 4 Not Applicable
Family Acceptance	Family Acceptance 1 Very Important	Family Acceptance 2 Important	Family Acceptance 3 Not Important	Family Acceptance 4 Not Applicable
Helpline	Helpline 1 Very Important	Helpline 2 Important	Helpline 3 Not Important	Helpline 4 Not Applicable

Other

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13. TRAINING NEEDS: Please rate the importance for each of the following training needs:

	1 Very Important	2 Important	3 Not Important	4 Not Applicable
Phone Support: Special Education / Disability Support	*TRAINING NEEDS: Please rate the importance for each of the following training needs: Phone Support: Special Education / Disability Support 1 Very Important	Phone Support: Special Education / Disability Support 2 Important	Phone Support: Special Education / Disability Support 3 Not Important	Phone Support: Special Education / Disability Support 4 Not Applicable
1:1 Meeting: Special Education / Disability Support	1:1 Meeting: Special Education / Disability Support 1 Very Important	1:1 Meeting: Special Education / Disability Support 2 Important	1:1 Meeting: Special Education / Disability Support 3 Not Important	1:1 Meeting: Special Education / Disability Support 4 Not Applicable
Special Education / Disability Support (how to start the process)	Special Education / Disability Support (how to start the process) 1 Very Important	Special Education / Disability Support (how to start the process) 2 Important	Special Education / Disability Support (how to start the process) 3 Not Important	Special Education / Disability Support (how to start the process) 4 Not Applicable
Special Education / Disability Support (working with the district)	Special Education / Disability Support (working with the district) 1 Very Important	Special Education / Disability Support (working with the district) 2 Important	Special Education / Disability Support (working with the district) 3 Not Important	Special Education / Disability Support (working with the district) 4 Not Applicable
Special Education / Disability Support (behavior strategies)	Special Education / Disability Support (behavior strategies) 1 Very Important	Special Education / Disability Support (behavior strategies) 2 Important	Special Education / Disability Support (behavior strategies) 3 Not Important	Special Education / Disability Support (behavior strategies) 4 Not Applicable
Special Education / Disability Support (infant & child health)	Special Education / Disability Support (infant & child health) 1 Very Important	Special Education / Disability Support (infant & child health) 2 Important	Special Education / Disability Support (infant & child health) 3 Not Important	Special Education / Disability Support (infant & child health) 4 Not Applicable
Special Education / Disability Support (safety, nutrition & fitness)	Special Education / Disability Support (safety, nutrition & fitness) 1 Very Important	Special Education / Disability Support (safety, nutrition & fitness) 2 Important	Special Education / Disability Support (safety, nutrition & fitness) 3 Not Important	Special Education / Disability Support (safety, nutrition & fitness) 4 Not Applicable
Special Education / Disability Support (developmental & behavioral health)	Special Education / Disability Support (developmental & behavioral health) 1 Very Important	Special Education / Disability Support (developmental & behavioral health) 2 Important	Special Education / Disability Support (developmental & behavioral health) 3 Not Important	Special Education / Disability Support (developmental & behavioral health) 4 Not Applicable
Special Education / Disability Support (parenting)	Special Education / Disability Support (parenting) 1 Very Important	Special Education / Disability Support (parenting) 2 Important	Special Education / Disability Support (parenting) 3 Not Important	Special Education / Disability Support (parenting) 4 Not Applicable
Special Education / Disability Support (early learning)	Special Education / Disability Support (early learning) 1 Very Important	Special Education / Disability Support (early learning) 2 Important	Special Education / Disability Support (early learning) 3 Not Important	Special Education / Disability Support (early learning) 4 Not Applicable
Special Education / Disability Support (child care, preschool & early education)	Special Education / Disability Support (child care, preschool & early education) 1 Very Important	Special Education / Disability Support (child care, preschool & early education) 2 Important	Special Education / Disability Support (child care, preschool & early education) 3 Not Important	Special Education / Disability Support (child care, preschool & early education) 4 Not Applicable
Special Education / Disability Support (transition to adulthood)	Special Education / Disability Support (transition to adulthood) 1 Very Important	Special Education / Disability Support (transition to adulthood) 2 Important	Special Education / Disability Support (transition to adulthood) 3 Not Important	Special Education / Disability Support (transition to adulthood) 4 Not Applicable
Special Education / Disability Support (family support services)	Special Education / Disability Support (family support services) 1 Very Important	Special Education / Disability Support (family support services) 2 Important	Special Education / Disability Support (family support services) 3 Not Important	Special Education / Disability Support (family support services) 4 Not Applicable
IEP Review	IEP Review 1 Very Important	IEP Review 2 Important	IEP Review 3 Not Important	IEP Review 4 Not Applicable

Other

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14. TECHNOLOGY: Please rate the importance for each of the following services for your learning needs:

	1 Very Important	2 Important	3 Not Important	4 Not Applicable
Webinars / Teleconference	*TECHNOLOGY: Please rate the importance for each of the following services for your learning needs: Webinars / Teleconference 1 Very Important	Webinars / Teleconference 2 Important	Webinars / Teleconference 3 Not Important	Webinars / Teleconference 4 Not Applicable
Website Information	Website Information 1 Very Important	Website Information 2 Important	Website Information 3 Not Important	Website Information 4 Not Applicable
Fact Sheets	Fact Sheets 1 Very Important	Fact Sheets 2 Important	Fact Sheets 3 Not Important	Fact Sheets 4 Not Applicable
Publications	Publications 1 Very Important	Publications 2 Important	Publications 3 Not Important	Publications 4 Not Applicable
Newsletter	Newsletter 1 Very Important	Newsletter 2 Important	Newsletter 3 Not Important	Newsletter 4 Not Applicable
Agency Resource Fair	Agency Resource Fair 1 Very Important	Agency Resource Fair 2 Important	Agency Resource Fair 3 Not Important	Agency Resource Fair 4 Not Applicable

Other

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15. RESOURCES: Please rate the importance for each of your following resource needs:

	1 Very Important	2 Important	3 Not Important	4 Not Applicable
Locating Services for Early Intervention Child	*RESOURCES: Please rate the importance for each of your following resource needs: Locating Services for Early Intervention Child 1 Very Important	Locating Services for Early Intervention Child 2 Important	Locating Services for Early Intervention Child 3 Not Important	Locating Services for Early Intervention Child 4 Not Applicable
Locating Services for School Age Child	Locating Services for School Age Child 1 Very Important	Locating Services for School Age Child 2 Important	Locating Services for School Age Child 3 Not Important	Locating Services for School Age Child 4 Not Applicable
Locating Services for Transition to Adulthood	Locating Services for Transition to Adulthood 1 Very Important	Locating Services for Transition to Adulthood 2 Important	Locating Services for Transition to Adulthood 3 Not Important	Locating Services for Transition to Adulthood 4 Not Applicable
Locating Services for Adulthood	Locating Services for Adulthood 1 Very Important	Locating Services for Adulthood 2 Important	Locating Services for Adulthood 3 Not Important	Locating Services for Adulthood 4 Not Applicable
Community Resources (list below in detail)	Community Resources (list below in detail) 1 Very Important	Community Resources (list below in detail) 2 Important	Community Resources (list below in detail) 3 Not Important	Community Resources (list below in detail) 4 Not Applicable

Community Resources (what the parent needs for the individual with disabilities - please list in detail)

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16. Of the following communication method types, please rank how you prefer to access information.

	Communication Preference #1	Communication Preference # 2	Communication Preference #3	Communication Preference #4	Communication Preference #5
Choice:	Of the following communication method types, please rank how you prefer to access information. Choice: Communication Preference #1	Communication Preference # 2	Communication Preference #3	Communication Preference #4	Communication Preference #5

Other (please specify)

17. Please feel free to add any other comments in the below section:

Please feel free to add any other comments in the below section: