Supports for Individuals Survey

Over the last year you have received support from a program connected with the Edmonton and area Fetal Alcohol Network Society. Thank you for taking the time to complete this survey. Your responses are entirely voluntary, and you may refuse to complete any part or all of this survey. The survey measures the way you feel about the support services you have received. Please answer openly and honestly.

Question Title

* 1. Please enter the date the survey was completed.

Date

Question Title

* 2. Please select the agency/program you are receiving services through.

Bissell Centre: FASS Program

Bissell Centre: Hope Terrace

CASA: Indigenous Services

Catholic Social Services: McDaniel Youth Program

Catholic Social Services: First Steps

Catholic Social Services: Step By Step Program

Elizabeth Fry Society: Girls Empowered and Strong Program

Leduc County: Bridges Program

Metis Nation of Alberta

Unlimited Potential: Open Arms Program

Other (please specify)

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* 3. Your age:

12 - 17 years old

18 - 24 years old

25 - 64 years old

65+ years old

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* 4. What gender do you identify as?

Male

Female

Trans-gender

Non-binary

Prefer not to answer

Other (please specify)

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* 5. Please check the box that best fits how you feel about the following questions/statements.

	I strongly disagree.	I disagree.	I neither agree or disagree.	I agree.	I strongly agree.	N/A
I am satisfied with the services I received from the agency/program.	I am satisfied with the services I received from the agency/program. I strongly disagree.	I am satisfied with the services I received from the agency/program. I disagree.	I am satisfied with the services I received from the agency/program. I neither agree or disagree.	I am satisfied with the services I received from the agency/program. I agree.	I am satisfied with the services I received from the agency/program. I strongly agree.	I am satisfied with the services I received from the agency/program. N/A
Agency/program staff treat me with respect.	Agency/program staff treat me with respect. I strongly disagree.	Agency/program staff treat me with respect. I disagree.	Agency/program staff treat me with respect. I neither agree or disagree.	Agency/program staff treat me with respect. I agree.	Agency/program staff treat me with respect. I strongly agree.	Agency/program staff treat me with respect. N/A
I have an increased understanding of FASD and how it affects me.	I have an increased understanding of FASD and how it affects me. I strongly disagree.	I have an increased understanding of FASD and how it affects me. I disagree.	I have an increased understanding of FASD and how it affects me. I neither agree or disagree.	I have an increased understanding of FASD and how it affects me. I agree.	I have an increased understanding of FASD and how it affects me. I strongly agree.	I have an increased understanding of FASD and how it affects me. N/A
My level of stress has decreased.	My level of stress has decreased. I strongly disagree.	My level of stress has decreased. I disagree.	My level of stress has decreased. I neither agree or disagree.	My level of stress has decreased. I agree.	My level of stress has decreased. I strongly agree.	My level of stress has decreased. N/A
I have experienced an improvement in my wellbeing.	I have experienced an improvement in my wellbeing. I strongly disagree.	I have experienced an improvement in my wellbeing. I disagree.	I have experienced an improvement in my wellbeing. I neither agree or disagree.	I have experienced an improvement in my wellbeing. I agree.	I have experienced an improvement in my wellbeing. I strongly agree.	I have experienced an improvement in my wellbeing. N/A
I have been given information and resources regarding FASD and supports available to me.	I have been given information and resources regarding FASD and supports available to me. I strongly disagree.	I have been given information and resources regarding FASD and supports available to me. I disagree.	I have been given information and resources regarding FASD and supports available to me. I neither agree or disagree.	I have been given information and resources regarding FASD and supports available to me. I agree.	I have been given information and resources regarding FASD and supports available to me. I strongly agree.	I have been given information and resources regarding FASD and supports available to me. N/A
I am involved in planning the services I receive.	I am involved in planning the services I receive. I strongly disagree.	I am involved in planning the services I receive. I disagree.	I am involved in planning the services I receive. I neither agree or disagree.	I am involved in planning the services I receive. I agree.	I am involved in planning the services I receive. I strongly agree.	I am involved in planning the services I receive. N/A

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* 6. The agency/program helped me in the following areas: (Please check all that apply).

Physical Health (doctor, dentist, nutritionist, recreation...)

Attachment (emotional bond with child, playing together...)

Family Cohesion (safety, stability)

Social Functioning (healthy social gatherings)

Mental Health and Regulation (referral and access, strategies...)

Education (school attendance, education supports...)

Identity (strengths, interests, cultural connections...)

Community Engagement (things to do, social network...)

Adaptive Skills (routines, schedules, hygiene, taking the bus...)

Employment and Finances

Housing

Parenting (skills development)

Access to FASD assessment services

Access to other community resources

Other (please specify)

Question Title

* 7. I require further assistance in the following areas: (Please check all that apply).

Physical Health (doctor, dentist, nutritionist, recreation...)

Attachment (emotional bond with child, playing together...)

Family Cohesion (safety, stability)

Social Functioning (healthy social gatherings)

Mental Health and Regulation (referral and access, strategies...)

Education (school attendance, education supports...)

Identity (strengths, interests, cultural connections...)

Community Engagement (things to do, social network...)

Adaptive Skills (routines, schedules, hygiene, taking the bus...)

Employment and Finances

Housing

Parenting (skills development)

Access to FASD assessment services

Access to other community resources

Other (please specify)

Supports for Individuals Survey