SATISFY-User Profile

SATISFY User Profile

Please fill out the user profile to participate in the SATISFY project. The information you provide will only be used by the SATISFY team to communicate with you about future surveys, survey results and important SATISFY announcements.

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* 1. Name or username: May use first name, screen name or username.

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* 2. Please provide your email address. You will be asked to enter your email on four additional surveys we will ask you to complete. We will only use your email to match your surveys, and we will not share the information outside of the SATISFY team.

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* 3. State of residence

I live in California

I live outside of California

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* 4. Which description best matches your role?

Other caregiver of a child/children receiving regional center services (please describe)

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* 5. What condition(s) make the child/children about whom you are responding eligible to receive services through a regional center? You may respond with up to two children, and you may indicate multiple conditions. You must indicate at least one condition per child.

	Autism	Cerebral palsy	Epilepsy	Intellectual disability	Condition requiring similar supports/services needed for a person with an intellectual disability
Child 1	Child 1 Autism	Child 1 Cerebral palsy	Child 1 Epilepsy	Child 1 Intellectual disability	Child 1 Condition requiring similar supports/services needed for a person with an intellectual disability
Child 2	Child 2 Autism	Child 2 Cerebral palsy	Child 2 Epilepsy	Child 2 Intellectual disability	Child 2 Condition requiring similar supports/services needed for a person with an intellectual disability

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* 6. What is the age of the child/children about whom you are responding? You may respond with up to two children.

	2 and under	Between 3 and 11	12-18	19-22	Over 22
Child 1	Child 1 2 and under	Child 1 Between 3 and 11	Child 1 12-18	Child 1 19-22	Child 1 Over 22
Child 2	Child 2 2 and under	Child 2 Between 3 and 11	Child 2 12-18	Child 2 19-22	Child 2 Over 22

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* 7. What is your race/ethnicity? You may select more than one answer.

American Indian or Alaska Native

Asian

Black or African American

Hispanic, Latino/Latina/Latinx, or Spanish

Middle Eastern or North African

Native Hawaiian or other Pacific Islander

White

Decline to answer

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* 8. From which regional center does the child/children about whom you are responding receive services? If you aren't sure about your regional center catchment area find it here.

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* 9. By checking the boxes below, you:

Acknowledge that the information that you provide in this registration form and in the follow-up surveys is being provided voluntarily

Consent to the use of the information that you provide in this registration form and in the follow-up surveys for the purposes of research by the Department of Developmental Services and WestEd