We consistently work to enhance the quality of our programs and services. To do so, we rely on information, interest, and input from our local community. Please take our brief questionnaire to help us better serve you. All information shared with us remains confidential.

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* Caregiver #1 Information

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* What is your relationship to your loved one with Down syndrome?

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* What are your preferred pronouns?

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* Which race or ethnicity best describes you?

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* Caregiver #2 Information

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* What is your relationship to your loved one with Down syndrome?

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* What are your preferred pronouns?

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* Which race or ethnicity best describes you?

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* Individual with Down syndrome Information

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* What are their preferred pronouns?

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* Which race or ethnicity best describes them?

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* Where does your loved one reside?

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* Type of Down syndrome

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* When were you given your diagnosis?

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* Medical Conditions / Secondary Diagnosis

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* Do you have a waiver?

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* What means of transportation does your loved one utilize?

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* Please check all the services/therapies that you currently utilize.

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* If your loved one is currently enrolled in SCHOOL, please answer the following questions.

  Yes/ No
Do you currently have a behavior plan?
Did you complete an outpatient physio-evaluation?
Did you receive Extended School Services in 2022?

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* School Information

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* If your loved one is an ADULT, please answer the following questions.

  Yes / No
Does the adult with Down syndrome receive Social Security?
Is the adult with Down syndrome their own guardian?
Have you received our Adult Healthcare Guidelines from us in the mail?
Is there an adult sibling that would like to receive our information?
Is the adult with Down syndrome employed?

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* If adult with Down syndrome is employed, please list the employer.

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* If an adult sibling would you like to receive our information, please provide their email and/or phone number.

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* Would you be interested in any of the following DSAGC support services? These are available at no cost to families.

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home or hospital visit from our Early Matters Coordinator
connections and/or information about Early Intervention Services
School Age Coordinator attend a school or behavior meeting as a liaison
School Age Coordinator review IEP or other school-related documents
Outreach Specialist give a Peer Presentation in the classroom
connections and/or information about School Services
Adult Coordinator attend day programs or job sites to provide support
Adult Coordinator assist in the preparation of future planning documents
connections and/or information about Adult Services (such as housing, transportation, healthcare, social opportunities, or aging)
Giving Tree Program (lending a helping hand to families during the holiday season)
Transportation Assistance Fund (financial assistance to obtain dependable and convenient transportation to DSAGC programs and/or medical appointments)
Community Participation Fund (scholarships to participate in community activities)
Lending Library (books about Down syndrome available to borrow)

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* Would you attend our annual Summer Picnic if it were held at...? Check all that apply.

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* What type of venue does your family prefer for the Summer Picnic?

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* What day/time works best in your schedule to attend the Summer Picnic?

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* Typically, our Summer Picnic is free to attend. However, if the Summer Picnic were held at a large venue, would you be ok to pay a minimal/extremely discounted admission fee?

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* Would you attend our annual Holiday Party if it were held at...? Check all that apply.

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* What type of venue does your family prefer for the Holiday Party?

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* What day/time works best in your schedule to attend the Holiday Party?

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* Typically, our Holiday Party is free to attend. However, if the Holiday Party were held at a large venue, would you be ok to pay a minimal/extremely discounted admission fee?

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