* 3. What type of support and care do you / and your family provide for your children?
(Select all that apply)

  You Your Partner Siblings Other Family Members
Personal
Physical
Medication
Medical
Therapies
Safety
Emotional
Behavioural
Communication
Social
Transportation
Other

* 6. What impact does the current support have on you and your family?
(Please indicate where you are on the scale)

  Worst Best
Energy Levels (Constantly tired / Energetic)
Emotionally (Depressed / Happy)
Health (Often ill / Fit & Healthy)

* 7. If your child was to use the new short break facility, what would you like to see provided?
(Please use your imagination).

* 8. Which features would you most like to see in a short break facility?
(Please put in order of priority)
1=Most important
10=Least important

* 9. Would you be interested in learning more about 'Give Us A Break' and the new Short Break Centre?
If so, please leave your contact details in the space below.

T