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2019 MyGOAL Needs Assessment Survey

This is a 5 minutes survey that will help us to determine what services/programs families have or think they willl need for their loved one with a disability. This will help us to design programs that will help us to better serve you.

1. Indicate if you are a: *This question is required.

Please enter an 'other' value for this selection.

2. What is your gender *This question is required.

3. Age Range *This question is required.

<20 years	20-30 years	31-40 years	41-50 years	51-60 years	>61 years
<20 years	20-30 years	31-40 years	41-50 years	51-60 years	>61 years

4. Ethnicity *This question is required.

5. Number of children with diagnosis *This question is required.

Please enter an 'other' value for this selection.

6. Age of child (individual) with disability *This question is required.

<3 years	3-4 years	5-13 years	14-17 years	18-21 years	>21 years
<3 years	3-4 years	5-13 years	14-17 years	18-21 years	>21 years

7. Gender of child with disability *This question is required.

8. Age of second child (individual) with disability if applicable

9. Gender of second child with disability if applicable

10. Type of diagnosis *This question is required.

11. What is the Severity of the Child(ren)'s diagnosis? *This question is required.