1. Respite Care Needs Survey


* 1. In what locale do you live?

* 2. What days of the week would respite care support your needs? (check all that apply)

* 3. What time of day would respite care support your needs? (check all that apply)

  Preferred Time Alternate Preferred Time Not Needed
Early Morning (before school/work)
Late Afternoon (after school/work)
Weekday Evenings (6pm-10pm)
Weekends Daytime
Weekend Evenings

* 4. What are the primary reasons you would use respite care?

* 5. What is the age range of your family member(s)?

* 6. Rate the importance of the following program components.

  Extremely Important Somewhat Important Less Important N/A
Staff to participant ratio
On-site activities (participant remains on-site)
Community activities (i.e. bowling, movies)
Monthly calendar of planned activities
Behavior Support
Cost of program

* 7. What is your vision of a respite program? Dream Big!!

* 8. This survey is anonymous. If you would like to provide your contact information so we can address any questions or concerns you may have, please submit with this survey.