* 1. Age of individual with special needs/disabilities

* 2. Gender of individual with special needs/disabilities

* 3. Diagnosis (if known, check all that apply)

* 4. As a result of their disability, does the individual have difficulty
with: (check all that apply)

* 5. What is your relationship to the individual with special needs/disabilities?

* 6. What is your age? (Caregiver age)

* 7. How many individuals with special needs/disabilities do you provide care for? (Please enter number below)

* 8. Do the individuals with special needs/disabilities live at home?

* 9. Is there anything else you would like to share about the individual with special needs/disabilities, the primary caregiver, or anything else?

* 10. If you would like to have a conversation about your experience
related to disability and accessing support, please enter your
name, telephone number and/or your email address and we will contact you to plan the best date and time.