Exit Main Street 1 - For Caregivers Community Survey Question Title * 1. How old is your child/young adult/adult with special needs? Under 10 Between 11-20 Between 21-30 Above 30 Question Title * 2. What is/are your child's diagnosis? Developmental Delays Autism Diagnosis Learning Disabilities ADHD/Executive Functioning Other Question Title * 3. What is the sex of your child? Male Female Question Title * 4. Which region of the DC area would be your/their living preference? Rockville Bethesda Silver Spring DC Northern Virginia Gaithersburg/Germantown comments: Question Title * 5. What type of dwelling would you/your child prefer? Rental Apartment Condominium Townhome Single Family House/Group Home Question Title * 6. Would your child want a roomate? want to live alone? need a room for a caregiver? Other (please specify) Question Title * 7. What is your family income? Under $100,000.00 $100,000-$250,000.00 Above $250,000.00 Question Title * 8. What is your child's favorite activity? Question Title * 9. What type of programming would your child need? Complete boxes below. Social: Therapeutic: Educational: Other: Question Title * 10. What level of social interaction does your child prefer? Lots of social action Limited social action Very little social action Question Title * 11. If over 18/21, do you receive DDA supports or any type of housing waiver? Yes No In progress Other (please specify) Question Title * 12. When would you consider moving into an inclusive living option? Within the next year 2018-19 2019-20 2020-21 Done
