Southeastern Regional Foundation for Autism Spectrum Disorders
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SERFASD
 

What is Autism?

What is Asperger Syndrome?

ASD Community Survey

ASD Community Survey

Important -- Please Read Carefully

The Southeastern Regional Foundation for Autism Spectrum Disorders (SERFASD) is a grassroots organization of parents and other individuals whose goal is to provide services and support to individuals and families affected by an ASD diagnosis. We are currently looking for your input for the development of a 5-year plan (2006-2011). This questionnaire is for informational purposes only!!! However, the information gathered may be used by SERFASD to devise and implement new programs in the Gulf Coast area and, in doing so, summaries of the responses to this questionnaire may be shared with other existing community agencies. In that event, no personally identifying information will be released but we request that you choose carefully when deciding upon whether to provide the personal information requested at the end of the questionnaire. Thank you for your input!!!


1. Location:

City:   .State:  

2. Please check the statement that best describes you:


3. Please check all that apply to you:

Race:
 
 

Age: 19-24 25-34 35-44 45+

Sex: Male Female

Marital Status: Single Married Divorced Widowed

Median Household Income:  

4. If you are the parent or family member of a person diagnosed with an ASD, please provide the following information about the diagnosed person:

Age: 1-3 4-6 7-9 10-12 13-15
  16-18 19-25 26-34 35-45 45+

Sex: Male Female

Number of Other Children in Household:

Number of Other Children with ASD Diagnosis:

Age of ASD Person at Time of Diagnosis:
  1-3 4-6 7-9 10-12 13-15
  16-18 19-25 26-34 35-45 45+

5. Please check ALL that apply to ASD diagnosed person:


6. In what setting is ASD person (if school-aged) receiving education:

Private School Public School Home School
Other:

If ASD person is being home schooled, please explain as breifly as possible your reason(s) for removing child from the traditional-type school setting:


7. Please rate the item listed in each category below in order of their importance to your with the number 1 being of highest importance:

  Childcare:
  Infant/Child Daycare for Children with ASD
  After School Care
  In-Home Sitting Service
  Respite Care (Short Term)
  Respite Care (Long Term)

  Education/Early Intervention:
  Workshops/Seminars
  Professional Development (Medical Practitioners, Therapists, Teachers, etc)
  Community Awareness Programs (Student Workshops, Advertisements, etc.)
  IEP Support (Development, Advocacy, etc.)
  Private Developmental Education by ASD Aware Individuals
  Post-Secondary Education

  Recreation:
  Camp (Daycamp, Winter/Summer Camp, Weekend Retreats, etc.)
  Social Opportunities (Group Activities/Excursions)
  Family Outings (Picnics, Camping, etc.)

  Health:
  Cost of Medication
  Least Restrictive Prescription/Regulation/Administration (Medication(s))
  Insurance Advocacy
  Animal Therapy

  Employment:
  Special Interest Development Programs
  Job Training
  Transportation

  Formal Community Supports:
  Networking
  Integration of Existing Community Services
  ASD Training for Community Law Enforcement, Fire, and First Reponders

  Informal Community Supports:
  Active Support Group
  Family Mentoring
  Lending Library
  Community Fundraising for Specific Programs

  Quality Assurance:
  Directory of Preferred Care Providers
  Advocacy for Attracting New Care Providers

  Please choose what you feel to be the single most important service/activity listed above. Describe what you believe is the major hurdle to providing that service/activity and any suggestions you may have on how to improve that situation:
 

8. Please give your recommendation for the "The Best of..." and provide the city and state in which the practitioner is located:

General Pediatric Doctor:
Specialist M.D.:
Neurologist:
Psychologist:
Occupational Therapist:
Physical Therapist:
Behavioral Therapist:
Top 2 Schools: 1-
  2-
Top 2 Teachers & their Schools: 1-
  2-

9. Is there a topic that you would like to have addressed by a specific speaker at a monthly support group meeting and/or discussed in a monthly newsletter?

10. Thank you for your participation in the survey. If you would like to receive a copy the survey results, please provide the following information:

Name:
Address:
 
City, State Zip:
E-Mail:

 

 
 
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