Autism 

Name (optional):

Relationship to Individual with an ASD:

Age and Gender of Individual with an ASD:  _________                  Male  /  Female

Autism Resources Miramichi Inc. will be presenting several free workshops in the future.  In order to provide the workshops that best fit the interest of families and support workers in our area, we would appreciate it if you could take a few moments to fill out this brief survey to give us a better idea or areas we should focus on. 

For each question below, circle the number to the right
that best fits your opinion on the importance of the issue.
Use the scale above to match your opinion.

Workshop(s) on:

Scale of Importance

Not at all

Not very

No Opinion

Some-what

Extremely

Dietary and feeding issues

1

2

3

4

5

Behaviour issues

1

2

3

4

5

Social Stories

1

2

3

4

5

Social Skills Training

1

2

3

4

5

Visual Supports

1

2

3

4

5

Improving communication

1

2

3

4

5

Applied Behaviour Analysis

1

2

3

4

5

Self-Help skills (toileting/dressing, etc.)

1

2

3

4

5

Sensory issues

1

2

3

4

5

Aspergers

1

2

3

4

5

Adolescent and Teenage Issues

1

2

3

4

5

Sleep Issues

1

2

3

4

5

Disability Tax Credit / Child Disability Allowance

1

2

3

4

5

Other:_________________________________

1

2

3

4

5