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Caregiver/Parent Feedback Questionnaire
Questionnaire
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1.
What does the word autism mean for you?
(Required.)
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2.
How do you prefer to describe your child's / loved one's diagnosis? (please select one)
(Required.)
Person with autism
Autistic person
Person with ASD
Person with Autism Spectrum Disorder
On the spectrum
On the Autism Spectrum
Neurodivergent
Neurodiverse
I Use multiple
I don’t use any of the above listed
It doesn’t matter to me
I use something else (please specify)
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3.
Please provide any additional information on why you made that choice
(Required.)
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4.
When looking for support for your child / loved one, what are you looking for? (please select all that apply)
(Required.)
Treatment
Programs (for example: skill building programs, play programs, communication programs, etc.)
Therapy
Intervention
Coaching
Services
Consultation
Respite
Something else (please describe)
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5.
Who are you looking for to support your child / loved one? (please select all that apply)
(Required.)
Teacher
Therapist
Instructor
Facilitator
Coach
Worker
Support worker
Something else (please describe)
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6.
Is there anything else you think is important that we have missed or that you’d like to share with us? Your thoughts and ideas matter to us!
(Required.)
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7.
Can we reach out to you for more feedback?
(Required.)
Yes
No
