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* 1. Are you a mom or a caregiver of a special needs child/adult?
(Special Needs = person who has more needs than a typical person, ex: foster, adopted, developmentally delayed, trauma…)

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* 2. Do have the opportunity for self-care?

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* 3. What prevents you from self-care? (check all that apply)

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* 4. Check all things that you would LIKE to do:

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* 5. Check all the things you did at least once in the last 6 months:

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* 6. Do you have someone who could watch your children while you do self-care?

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* 7. Do you have Habilitation/Respite hours from DDD?

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* 8. If you answered "yes" do you need a provider?

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* 9. Would you be interested in attending any of the following?

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* 10. Please also enter your information so we can contact you about our self-care giveaways and other opportunities.

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