Caregiver Support Group Survey

Helping Us Help You – Your Voice Shapes the Space

SECTION 1: About You

1. Name (Optional)

2. Zip Code

3. What is your relationship to the child?
ParentGrandparentFoster ParentLegal GuardianOther

4. What is your race/ethnicity? (Select all that apply):
Black / African AmericanCarribeanLatinx / HispanicIndigenousMultiracialOther

5. Preferred Language(s)

6. How many children with autism are you caring for?
123+

SECTION 2: About Your Children

7. Age(s)

8. Is your child:
VerbalNon-VerbalSemi-VerbalUses AAC deviceOther

9. Any dietary restrictions or allergies we should know about?
NoYes (please list)

10. Does your child have any sensory sensitivities or behaviors we should be mindful of during group time? UnsureNoYes (Please explain briefly)

SECTION 3: Support Needs
11. What kind of support do you need the most right now? (Check all that apply):
Emotional Support from other caregiversNavigating IEPs / school systemsAccessing therapies or servicesHousing or legal advocacyMental Health resources for caregiversActivities or enrichment for your childHelp managing behaviorsOther

12. What’s been the hardest part of your journey lately? (Open Response)

SECTION 4: Meeting Preferences
13. Would you be interested in attending: In-person meetingsVirtual MeetingsBoth

14. What days generally work best for you? (Select all that apply):
MondayTuesdayWednesdayThursdayFriday

15. What times generally work best for you? (Select all that apply):
Afternoon (12PM – 4PM)Early Evening (4PM – 6PM)Evening (6PM – 8PM)Late Evening (After 8PM)

16. If attending in person, would you need childcare? YesNoMaybe

17. If childcare is provided, would you prefer:
My child stays in the same room as meMy child is separate with trained staffIt depends – Please Explain

18. What would make this support group feel like a safe, empowering space for you? (Open Response)

19. Is there anything else you want us to know about you or your child(ren)? (Open Response)

20. Would you like to be added to our contact list for updates and events?
Yes, my email is:
Yes, my phone is:
No thanks

Please leave this field empty.