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  • 2017 Children's Community Options Program (CCOP) Questionnaire
     

    IMPORTANT REMINDER: YOU MUST RETURN THIS QUESTIONNAIRE BY DECEMBER 9, 2016
    FOR YOUR CHILD TO REMAIN ON THE 2017 CHILDREN'S COMMUNITY OPTIONS PROGRAM WAIT LIST. 

    *If you complete the questionnaire online for 2017, we will automatically add you to the electronic mailing.

     
      
    Child's Name:
    Diagnosis 1
    Diagnosis 2
    Diagnosis 3



    Please answer the following questions comparing your child to a typically developing child.

    1. The word that best describes my child's physical health is:
        
    2. My child's disability affects his/her ability to participate in typical daily activities.
        
    3. Age appropriate activities of daily living involving physical and personal care needs:
        
    4. Age appropriate mobility needs:
        
    5. Communication skills:
        
    6. Cognitive and/or developmental abilities:
        
    7. Emotional/behavioral issues:
        
    8. My child interacts with peers in an age appropriate manner.
        
    9. Your child's medical needs within the last year:
        
    10. Your child's mental health needs or services received within the last year:
        
    11. How many, if any, of the parents or guardians that provide day-to-day care for the child with disability have their own disabling condition?
       
    12. How many, if any, of your child's brother(s) and/or sister(s) who live in the same household, have their own disabling condition?
       
    13. My child's behaviors, care, and/or time demands have prevented brother(s) and/or sister(s) from participating in activities.
        
    14. Are you a single parent with sole custody of your child with special needs?
        
    15. Do you have family members and/or friends providing you support?
        
    16. Our family's annual gross income range is:
        
    17. Please list the total number of children (including the child you are completing this for) living in your household under the age of 18:
    18. My child currently receives funding from the Children's Long Term Support (CLTS) Waiver (including the Autism program).
        
    19. My child's behavior is self-abusive.
        
       
    20. My child's behaviors are aggressive towards others.
        
       
    21. My child wanders or elopes with the intent of not returning.
        
       
    22. My child's needs affected a parent(s) employment status.
        
       
    23. My child's behavior and/or living environment places my child or others in imminent serious danger. (We define "imminent" as within the next year and we define "serious" as resulting in significant injury to self or others.)
        
       
    24. The Children's Community Options Program met our identified needs in 2016.
        
    25. Are you interested in receiving periodic email notifications that include information and services related to children with disabilities?
        
    26. Do you know that you are valued and heard as a parent of a child with special needs? The Special Services Advisory Committee (SSAC) wants your input into what you need as a parent from providers and agencies. If you would like to learn more, please answer YES and provide your Name, Telephone Number and Email Address below.