Parent / Caregiver Questionnaire
The Special Needs Program, at 2-1-1 First Call For Help, is the Hotline that provides comprehensive and relevant information and referrals to social service programs for the special needs community. It is specifically designed to be your comprehensive gateway to programs and services for children in Broward County with special needs and developmental disabilities (e.g. Autism, Cerebral Palsy, Down Syndrome, visual or hearing impairments).
Please take a moment to complete this brief voluntary questionnaire to help identify specific programs or services in
Broward County that you’ve found to be most helpful and accommodating to children with Special Needs. By providing this valuable information, you are assisting the 2-1-1 Special Needs Program to better identify individualized services for our callers (i.e. parents, caregivers, and other agencies). Please return it by mail, to the address below, or conveniently fax.
Thank you for your time and consideration.
Your Name (Voluntary): ___________________________ Your Broward Phone # (Voluntary): __________________
Would you like a Special Needs counselor to contact you? (Yes) / (No)
Primary disability of child: ________________________________________________________________
Other disability: ________________________________________________________________________
1. What do you see as being the major obstacle(s) to providing effective care to children and youth with special needs?
Comments:__________________________________________________________________________
__________________________________________________________________________
2. Which Pediatrician(s) do you find are most helpful serving your child or children with special needs?
Dr. _________________________________________________________________________________
Phone Contact Information (if known): _____________________________________________________
Dr. _________________________________________________________________________________
Phone Contact Information (if known): _____________________________________________________
3. Which Dentist or Dental Provider is most helpful to serving children and youth with special needs?
Dr. _________________________________________________________________________________
Phone Contact Information (if known): _____________________________________________________
4. Which attorney / advocate is most helpful to serving your child with special needs?
____________________________________________________________________________________
Phone Contact Information (if known): _____________________________________________________
5. Are there any additional program or service in Broward County that serves children or youth with special
needs that you also find helpful?
Program Name: _______________________________________________________________________
Contact Person: _______________________________________________________________________
Phone Contact Information (if known): ______________________________________________________
Program Name: _______________________________________________________________________
Contact Person: _______________________________________________________________________
Phone Contact Information (if known): ______________________________________________________
6. Additional Comments: _________________________________________________________________
_________________________________________________________________
Thank you for completing this survey.
Please either return by mail to: Special Needs Manager, 2-1-1 First Call For Help of Broward, 3217 NW 10th Terrace, Suite 307, Fort Lauderdale, FL 33309 or fax to (954) 390-0499
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