Adult Autism Needs Survey (short form)
We are taking this survey to learn more about how many people have autism spectrum disorders and to understand their abilities and needs. This information may help various organizations and support groups to provide the most useful supports to adults with autism and their families. This is the short form of a longer questionnaire, which we encourage you to complete if at all possible. Completing the longer form may help you--as an adult with autism or as a family member, friend or caregiver--to consider your current situation, various treatments and therapies, and how well you are planning for the future. Please know that the results of this survey will be grouped, and your individual responses will not be revealed to anyone else without your permission.
Q1 Initial letters of first and last names of person with autism (e.g., AB for Adam Brown)
Q2 Date of birth of person with autism in year/month/day order (e.g., 1978-05-06 for 6 May 1978)
Q3 Gender of person with autism
Q4 Municipality and province/state where person lives
Q5 At what age was the person diagnosed with autism?
Under 12 months
12 and under 24 months
24 months and under 36 months
36 and under 48 months
48 and under 60 months
5 and under 6 years
6 and under 10 years
10 and under 15 years
15 and under 20 years
20 and under 30 years
30 and under 40 years
40 and under 50 years
50 years or older
Don't know
Q6 Please quote keywords of the diagnosis
Q7 What is the person's cognitive or functioning level, as measured or generally assumed by others?
Severely-profoundly mentally handicapped
Mildly/moderately mentally handicapped
Above average
Uneven, all over the place
Q8 How does the person communicate in everyday life?
Speaking with no problems in being understood
Speaking with some impairment
Sign language
Facilitated Communicating
Picture Exchange Communication system
Acting out when upset or others do not understand
No communication at all
Some other method
Q9 What is the person's living situation?
With parents in family home
With sibling in family home
Foster home
Group home (with not more than 5 others) operated by non-profit agency
Group home (with not more than 5 others) by for-profit operator
Schedule I or II facility (with at least 50 other residents)
Nursing home
Supported Independent apartment alone
Apartment/townhouse shared with another disabled person
In own home with support
In own home independently
In some other living situation
Q10 In what main ways is the person's time spent on weekday? Please estimate the number of hours you spend in each of the following activities in an average week.
School-based programs.
1-10 hrs
11-20 hrs
21-30 hrs
31+ hrs
  College or university        
  Adult day programs        
  Sheltered workshop        
  Vocational training        
  Working for pay independently        
  Working for pay with support        
  Volunteering in community        
Q11 Overall, how well does the person with autism like her/his life as it is now?
Not all; my life is very poor
My life is only barelyadequate; there are many things to be changed
My life is pretty good most of the time, but a few things need to be improved
My life is very good; I want everything in my life to continue
Q12 If you live in the Region of Waterloo or in Guelph-Wellington County in Ontario, are you interested in the ASPIRE project that could help with information and resources for your situation?
Q13 Do you now receive case management and co-ordination services? Case management and service co-ordination assist individuals and families with disabilities (such as autism/pdd) in obtaining necessary clinical, educational, financial, medical, residential and social services. Trained service co-ordinators actively seek out services and entitlements and are advocates on behalf of the person and her/his family. The service co-ordinator meets with each family at least once a month to assess current services and supports, discuss and develop plans for new services and supports, and then try to procure them.
Q14 Would you, as an adult on the autism spectrum and/or a supporting family, want and need case management and co-ordination services?

Page 1/1