ASBH Family Needs Survey Question Title * 1. How many children do you have currently living at home? Children living at home: Question Title * 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 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Autism Child(ren)'s Current Age menu 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Autism Age(s) of Diagnosis menu Female Male Autism Gender menu Physician Psychologist Therapist Other(specify below) Autism Diagnosis Recieved From menu HF Autism 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 HF Autism Child(ren)'s Current Age menu 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 HF Autism Age(s) of Diagnosis menu Female Male HF Autism Gender menu Physician Psychologist Therapist Other(specify below) HF Autism Diagnosis Recieved From menu Aspergers 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Aspergers Child(ren)'s Current Age menu 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Aspergers Age(s) of Diagnosis menu Female Male Aspergers Gender menu Physician Psychologist Therapist Other(specify below) Aspergers Diagnosis Recieved From menu PDD-NOS 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 PDD-NOS Child(ren)'s Current Age menu 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 PDD-NOS Age(s) of Diagnosis menu Female Male PDD-NOS Gender menu Physician Psychologist Therapist Other(specify below) PDD-NOS Diagnosis Recieved From menu Other (please specify) Question Title * 3. Currently, do you have another child whom you suspect has an Autism Spectrum Disorder and is not formally diagnosed? Yes No Question Title * 4. Do you have other children that have disabilities that are not autism related (i.e. ADHD, Speech/Language Impairment, Specific Learning Disorder)? Yes No Question Title * 5. If yes, please list the diagnosis(es), age(s), and gender(s) below: Question Title * 6. Currently, do you have another child whom you suspect has a disability not related to autism and is not formally diagnosed? Yes No Question Title * 7. Have you utilized consultative or sought other professional services for your child(ren) with autism related disorders? Yes No Question Title * 8. If yes, who provided these services? (check all that apply) USD Center for Disabilities CCHS BHSSC Private Professional Other (specify below) Other (please specify) Question Title * 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) Sensory Integration OT/PT Speech/Language Other (please specify) Other (please specify) Question Title * 10. Has/have your child(ren)'s current staff received training and do you feel that they are knowledgeable about Autism Spectrum Disorders? Yes No Additional comments: Question Title * 11. Does your family currently belong to a parent support group? Yes No Question Title * 12. Are you aware of the Autism Society of the Black Hills? Yes No Question Title * 13. Have you taken advantage of programs offered through ASBH? (circle all that apply) Exploring Sports Program Swimming Program CAT Kit (CBT Therapy Based) Young Adults/Aspergers Peer Group Support Group Other (please specify) Question Title * 14. Have you or any family members attended workshops on autism? Yes No If yes, please list topics and locations: Question Title * 15. Does your family currently have a need for additional resources? Yes No Question Title * 16. If yes, please identify the areas of need below: General information or training regarding autism and related disorders Training on managing sleep difficulties, eating, toilet training, teaching appropriate community behavior, self injurious behavior, sensory, social or aggression, other (please specify below) Specific training on other issues of concern or key topics (please specify below) Information on current research related to Autism Spectrum Disorders Information on alternative treatment interventions (e.g. diets, vitamins, medications, alternative therapies) Access to specific topic resources including books, DVDs, materials Respite care and locating babysitters, care providers Information on adult services and adult transition issues Information on how to join or start a family support group in your area Support group and information specifically for families with multiple children with disabilities Information on sibling support issues or how to start a sibling support group in your area Additional details from above Question Title * 17. Please provide information regarding the SPECIAL CHALLENGES that your family faces due to having MORE THAN ONE child with a disability (if applicable): Question Title * 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: Question Title * 19. Check the appropriate box below if you would be willing to volunteer with the Autism Society of the Black Hills: Serve on the Board Assist with Fundraising Other (please specify) Question Title * 20. What is your approximate average household income? $0-$24,999 $25,000-$49,999 $50,000-$74,999 $75,000-$99,999 $100,000-$124,999 $125,000-$149,999 $150,000-$174,999 $175,000-$199,999 $200,000 and up Question Title * 21. What is the highest level of school you have completed or the highest degree you have received? Did not attend school 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade 7th grade 8th grade 9th grade 10th grade 11th grade Graduated from high school 1 year of college 2 years of college 3 years of college Graduated from college Some graduate school Completed graduate school Question Title * 22. How would you prefer to receive information from the Autism Society of the Black Hills? Facebook Email Autism Society Website Schools Other (please specify) Question Title * 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. Name: * Company: Address: * Address 2: City/Town: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * Country: Email Address: * Phone Number: Done