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Empowerment Parent Resource Center Needs Assessment : V2

Thank you for taking this short survey. We need your help in selecting priorities for the Empowerment Parent Resource Center (EPRC). Our mission is to provide useful referral, support, social, advocacy, training and educational services to parents, caregivers and youth with disabilities.

If you wish to be contacted, please select YES at the end of the survey and provide your contact information.

Please answer all questions and help guide us.

1. Name: (First and Last)

2. Select your gender.

3. If you are a parent/caregiver or a person with a disability, in which county do you reside?

Please enter an 'other' value for this selection.

4. If you are a parent or a person with a disability, please enter the 5-digit zip code of your residence. This will help us know which locations in our service area need help.

5. If you are a professional, provider, government employee, school system employee or related, please select the counties that you serve. Please check all that apply.

Escambia
Santa Rosa
Okaloosa
Walton
Other County - Write In Please enter an 'other' value for this selection.
Not applicable

6. Are you a (check all that apply):

Parent or Caregiver of a Person with a Disability
Person with a Disability
Organization Representative that serves Families and/or Persons with a Disability (FPWD)
Community Organization Representative not serving FPWD
Government Employee
School System Employee
Other - Write In Please enter an 'other' value for this selection.

7. Please select your age group.

8. If you are a parent/caregiver of a person with disabilities, please select their age group. If there is more than one person with disabilities that you care for, please enter the youngest age.

9. For Parents or Caregivers of a Person with Disabilities and Professionals/Providers: As a parent or caregiver, please select all areas that you would like information or support with.

If you are a professional/provider, please select the need areas for the county(s) you serve specifically for parents and caregivers.

10. If you are interested in information for one or more specific disabilities, please list the disabilities here.

Option 1
Option 2
Option 3
Option 4

11. If you are needing support for one or more specific behaviors/issues, please briefly describe them here.

12. If Answering for a Person with Disabilities: If you are also answering for someone with disabilities as a parent or caregiver, please select all areas that you would like information or support for him or her.

If you are a professional/provider, please select the need areas for the county(s) you serve specific for persons with disabilities.

13. For Youth or Young Adult (age 13-26) with Disabilities: If you are a person with a disability age 13-26, please select any areas that you would like information and support on.

Education support
Social networking, friends and reducing isolation
Planning for independence
Self-advocacy skills
Improving natural supports
Other 1 Please enter an 'other' value for this selection.
Other 2 Please enter an 'other' value for this selection.
Other 3 Please enter an 'other' value for this selection.

14. Do you want to be contacted by a Resource Specialist from the EPRC?

15. If you answered YES to question 14, please enter your contact information.

Telephone number (###-###-####)
Email address (please double check!)