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* 1. Name:

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* 2. Address

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* 4. Phone

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* 5. Gender:

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* 6. Age:

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* 7. Which of the following best describes your race?

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* 8. Do you have any school-aged children living in your household for whom you are legally and financially responsible? School-aged meaning Kindergarten through Twelfth grade.

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* 9. What are the age(s) of your child(ren)?

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* 10. What is your role in making decisions regarding education for the child(ren) in your household?

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* 11. What was your approximate annual household income for 2023, before taxes, from all sources? This includes salaries, Social Security, pension, interest, and investment earnings.

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* 12. What type of school is your child/are your children attending currently?

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* 13. Many children experience one or more of the following developmental or learning differences. Has your child/any of your children been diagnosed with or do you believe they might be experiencing any of the following.

  My child(ren) has/have received this diagnosis I believe my child(ren) is/are experiencing this My child(ren) definitely does/do not experience this Not sure
Dyslexia (difficulty reading)
Dysgraphia (difficulty writing)
Dyscalculia (difficulty in math)
Executive Function Disorder
ADD/ADHD
Auditory and/or Visual Processing Disorders
Hearing Impairment
Autism
Depression
Anxiety
Visual Impairment
Down-Syndrome

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* 14. In what grade(s) is/are your school aged child(ren)? Select all that apply.

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* 15. Has your child had an evaluation, test, or assessment to determine a diagnosis of their developmental and/or learning difference? In other words, has your child has a psychoeducational and/or cognitive evaluation or test to determine if your child has a learning difference.

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