Questionaire Survey Page

Assessment Questionnaire Survey

To get involved, you must first complete the survey below.

Guardian's/Self First Name

Guardian's/Self Last Name

Guardian's/Self Email

Best Phone Number

By providing your phone number, you agree to receive SMS [## 37067 ##] from the Center for ASD. Message frequency may vary. Standard Message and Data Rates may apply. Reply STOP to opt out. Reply HELP for help. We will not share mobile information with third parties for promotional or marketing purposes.

Participant's Name

Participant's Birthday required

IS YOUR LOVED ONE ABLE TO EXPRESS THEIR NEEDS AND WANTS? PLEASE EXPLAIN.

IS YOUR LOVED ONE AGGRESSIVE TO THEMSELVES OR OTHERS? IF YES, PLEASE EXPLAIN.

DOES YOUR LOVED ONE HAVE A HISTORY OF ELOPEMENT? IF SO, IS IT A CURRENT BEHAVIOR?

CAN YOUR LOVED ONE ATTEND TO THEIR OWN TOILETING NEEDS? IF NO, PLEASE EXPLAIN.

HOW DID YOU HEAR ABOUT US?

ADDITIONAL INFO

Our Family Liaison, Denise, will contact you at the email you provided to schedule a tour with you and your loved one. You will hear from us within 5–7 business days. Please be sure to check your SPAM folder if you don’t see the email in your inbox.

I have read and understand the information above.

Thanks for submitting! We will be in touch in 5-7 business days.