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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

Participant's Name

Participant's Birthday * required

WHICH PROGRAM(S) ARE YOU INTERESTED IN?

XCEL

REACH

CAMP

FIRST STEPS, THRIVE

TEENS, THRIVE

ADULT, THRIVE

THROWDOWN LOUNGE

KITCHEN CHAOS

#OTG

GROW

CAN YOUR LOVED ONE 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.