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* 1. How many children do you have currently living at home?

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* 2. Please indicate in the following chart the gender and diagnoses of your child(ren) with an Autism Spectrum Disorder:

  Child(ren)'s Current Age Age(s) of Diagnosis Gender Diagnosis Recieved From
Autism
HF Autism
Aspergers
PDD-NOS

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* 3. Currently, do you have another child whom you suspect has an Autism Spectrum Disorder and is not formally diagnosed?

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* 4. Do you have other children that have disabilities that are not autism related (i.e. ADHD, Speech/Language Impairment, Specific Learning Disorder)?

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* 5. If yes, please list the diagnosis(es), age(s), and gender(s) below:

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* 6. Currently, do you have another child whom you suspect has a disability not related to autism and is not formally diagnosed?

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* 7. Have you utilized consultative or sought other professional services for your child(ren) with autism related disorders?

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* 8. If yes, who provided these services? (check all that apply)

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* 9. Does your family/child(ren) receive any supplemental support services or additional therapies NOT PROVIDED within his/her educational program? (check all that apply)

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* 10. Has/have your child(ren)'s current staff received training and do you feel that they are knowledgeable about Autism Spectrum Disorders?

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* 11. Does your family currently belong to a parent support group?

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* 12. Are you aware of the Autism Society of the Black Hills?

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* 13. Have you taken advantage of programs offered through ASBH? (circle all that apply)

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* 14. Have you or any family members attended workshops on autism?

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* 15. Does your family currently have a need for additional resources?

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* 16. If yes, please identify the areas of need below:

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* 17. Please provide information regarding the SPECIAL CHALLENGES that your family faces due to having MORE THAN ONE child with a disability (if applicable):

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* 18. Please list any additional resources or services you believe would be beneficial for your family in order to better care for your child(ren) with disabilities:

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* 19. Check the appropriate box below if you would be willing to volunteer with the Autism Society of the Black Hills:

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* 20. What is your approximate average household income?

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* 21. What is the highest level of school you have completed or the highest degree you have received?

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* 22. How would you prefer to receive information from the Autism Society of the Black Hills?

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* 23. By providing your email address you will automatically be placed on our email list for families to receive regular information distrubuted by our group.

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