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Critical Needs Assessment for Families of Children
with Disabilities Impacted by Hurricanes

Thank you for participating in this survey. Our organization has received funding to support families with urgent needs resulting from the recent hurricanes. Please help us understand your needs by answering the following questions. Your responses will help us determine how to best support you and share essential information with stakeholders.
1.Please select your most critical need at this time
2.How many people are in your household (including children and adults)?
3.Please provide your zip code
4.What is the age of the child(ren) with disabilities in your household? (select all that apply)
5.Please provide the following demographic information
6.Are you a Medicaid recipient?
7.a.What is your child's school district?
7. b. Does your child have an Individualize Education Program (IEP) ?
8.Medical diagnosis of the child(ren) with disabilities in your household:
9.Estimated length of time services are needed: