Coffee and Conversations Wednesday Mornings

Join Coffee and Conversations on Wednesdays at 10am if you have children with behavioral challenges.

Question Title

* 1. Please provide your contact information.

Name (First and Last)

Email Address

Phone Number

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* 2. What county do you live in?

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* 3. What is your race?

Black or African American

White or Caucasian

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Multiple Races

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* 4. What is your ethnicity?

Hispanic or Latino

Non-Hispanic or Latino

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* 5. Please provide your child's date of birth.

Date of Birth

Date

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* 6. What is your child's race?

Black or African American

White or Caucasian

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Multiple Races

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* 7. What is your child's ethnicity?

Hispanic or Latino

Non-Hispanic or Latino

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* 8. What is your child's diagnosis? Please check all that apply.

Autism

ADD/ADHD

Deaf/Blind

Developmental Delay

Intellectual Disability

Deaf/Hearing Impairment

Emotional Disability

Learning Disability

Multiple Disabilities

Other Health Impairment

Orthopedic Impairment

Speech & Language

Traumatic Brain Injury

Vision Impairment/Blind

Suspected Disability

None

Other (please specify)

Coffee and Conversations *Wednesday Mornings*

Question Title

* 1. Please provide your contact information.

Question Title

* 2. What county do you live in?

Question Title

* 3. What is your race?

Question Title

* 4. What is your ethnicity?

Question Title

* 5. Please provide your child's date of birth.

Question Title

* 6. What is your child's race?

Question Title

* 7. What is your child's ethnicity?

Question Title

* 8. What is your child's diagnosis? Please check all that apply.

Coffee and Conversations Wednesday Mornings