Jill's House Needs Assessment Survey

Dear Families,

The mission of Jill’s House is to provide support and care to families with children with special needs in the Washington, DC metropolitan area through short-term overnight respite and therapy programs. Jill’s House will be located in Vienna, Virginia on property owned by McLean Bible Church.

Respite care is a remedy for the emotional, physical and financial hardships that families endure and is the most frequently requested support service. Often called "the gift of time," respite provides short-term care of people with disabilities while allowing the parent/caregiver necessary rest and relief.

We need your help to ensure that Jill’s House best meets the needs of the community. We are currently seeking information from families in the community to better understand which programs and services would be most beneficial to you and your children.

Your valuable input is greatly appreciated. Please take a few moments to answer the questions below. If you have any questions, please contact the Jill’s House office at 703-639-5660 or email us at survey@jillshouse.org.

Regards,
Tracy Key
Executive Director
Jill's House, Inc.

Jackie Mills-Fernald
Director
Access Ministry, McLean Bible Church




If you are a parent or guardian of more than one special needs child, please fill out the survey for each individual child to capture the child-specific information. All information obtained in this survey is confidential to be used solely for the development of the Jill’s House facility and its services. Your information will not be shared or sold to other agencies.



Jill's House 2008 Family Survey

Parent/Guardian Names (optional)
Address 1 (optional)
Address 2 (optional)
City
State
Zip
Email
Home Phone
Cell

Parent/Guardian Marital Status
Single
Married
Divorced
Other

Total number of children living at home

Total number of children at home with a disability diagnosis

My typical children's ages are

I would be willing to drive the following distance to use the Jill's House services:

Please estimate your one-way travel time (in minutes) to the Tyson's Corner, Virginia region from your current residence during RUSH HOUR.

Please estimate your one-way travel time (in minutes) to the Tyson's Corner, Virginia region from your current residence during NON-RUSH HOUR.

I currently obtain information about support services available for my special needs child/children through (please check all that apply):
My child's school
My church
List-serves
My county
My child's doctors/therapists
Local disability/advocacy organizations
Access Ministry at McLean Bible Church
Support groups
Other

I currently receive SUPPORT SERVICES for my special needs child/children from (please check all that apply):
My child's school
My church
My county
My child's doctors/therapists
Local disability/advocacy organizations
Access Ministry at McLean Bible Church
Other

Have you previously heard about Jill's House?
Yes
No

If you were designing a respite and therapy facility for children with disabilities, what services would be important for you to include?

Would you be willing to meet with us to discuss how we can structure programs and services to best serve your child?
Yes
No

Please provide a brief statement of how respite and therapy services provided through Jill's House would benefit you, your family and your child.

I would most like to receive updates about Jill's House via the following method:

My child with special needs is:
Male
Female

My child with special needs age is:

My child 's disability diagnosis is

My child with special needs attends the following school:

My child's school is in the following county:

My child with special needs school is:
Public
Private

My child with special needs school is located in the following zip code:

My child with special needs takes the bus to school.
Yes
No

My child with special needs has an Individualized Education Porgram (IEP).
Yes
No

My child with special needs is:
Verbal
Non-verbal

My child with special needs is:
Ambulatory
Non-ambulatory

My child with special needs uses the following medical equipment:

My child with special needs is on the following medications:

My special needs child has the following dietary restrictions/food allergies:

My child with special needs currently uses home-based respite care.
Yes
No

My child with special needs currently uses an out-of-home respite program.
Yes
No

I have the following number of children living at home with special needs who could use overnight respite care at Jill's House.

I would use temporary overnight respite care services at Jill's House for my child/children.
Yes
No

My child would require a private room for overnight care at Jill's House.
Yes
No

If both site-based and in-home respite care were offered by Jill's House, I would most likely use the following:
site-based respite care
in-home respite care

I would use Jill's House SITE BASED respite care MOST OFTEN during the following times:
Weekday overnights
Weekend overnights
School breaks
Summer break (1-2 weeks)
Evenings
Weekend days
Emergency stay

I would use Jill's House IN-HOME respite care (if offered) MOST OFTEN during the following times:
Weekday overnights
Weekend overnights
School breaks
Summer break (1-2 weeks)
Evenings
Weekend days
Emergency stay

I think we would use OVERNIGHT respite care for my child/children the following times per month:

I would use WEEKEND respite care for my child/children the following times per year:

I think we would use WEEK-LONG respite care for my child/children the following times during the school year:

I think we would use the WEEK-LONG respite care for my child/children the following times during the summer:

I would use Jill's House for emergency short-term stays.
Yes
No

I would pay privately (out-of-pocket) for overnight respite care.
Yes
No

I could pay the following per child for one night of respite care:

I would use the following Medicaid waiver program to pay for respite services:

If you answered other source of funds, please specify (optional).

I have the following number of respite hours available per month through our waiver program:

I have private insurance that would cover respite stays at Jill's House.
Yes
No

I have insurance for my child with the following company (optional):

My insurance will cover the following number of respite care hours per month:

I will use the following other sources of funds to pay for respite care (optional):

My child currently receives the following number of hours per week of therapy services covered by his/her IEP:

I currently supplement my child's IEP with the following number of hours per week of private therapy:

The therapies we currently supplement with are (please be specific):

Please select the therapy services that would be MOST important for your child to receive.
Physical Therapy
Occupational Therapy
Speech Therapy
Hydrotherapy
Recreational Therapy
Sensory Therapy
Vocational Therapy
Music/Art Therapy
Psychotherapy
Pet Therapy

Please select the therapy services that would be the LEAST important for your child to receive.
Physical Therapy
Occupational Therapy
Speech Therapy
Hydrotherapy
Recreational Therapy
Sensory Therapy
Vocational Therapy
Music/Art Therapy
Psychotherapy
Pet Therapy

I would use the following OTHER therapy services if they were available to my child (please be specific).

I could pay the following for one hour of therapy services:

I have insurance which pays for the following number of therapy hours per month:

My insurance pays the following rate per hour for therapy services:

My insurance is currently submitted by:
The therapy office
Individually

My insurance DOES NOT cover therapy services for my child, and I currently pay for therapy through:

My child currently receives early intervention services (services for children 0-5 years).
Yes
No

What early intervention services does your child receive?
Pre-school
Parent/child classes
Therapy services
Other

If your child currently receives early intervention services, how many hours per week do they receive?

The early intervention services my child receives are:
In-home
Outside-the-home

My child receives early intervention services from the following resource:

What early intervention programs do you wish your county offered that they currently don't?

I would use early intervention services at Jill's House for my child/children.
Yes
No

My special needs child currently attends pre-school.
Yes
No

I pay the following per month for pre-school:

I pay the following per year for pre-school:

My insurance will cover the following number hours of therapy services through early intervention programs.

I would be interested in parent/child early intervention classes at Jill's House.
Yes
No

I could pay the following per two hour pre-school class or parent/child class:

What other CHILD services would be beneficial to your child and/or family at Jill's House? Please check all that apply.
Dental
Optometry
Hair Salon
Tutoring
Vocational training
Other

What other FAMILY services would be beneficial at Jill's House? Please check all that apply.
Estate planning/legal services
Parent/guardian counseling
Family counseling
Sibling counseling (individual or group)
Sibling events/programs
Sibling overnight stays
Other

Does your special needs child currently have a dentist you are satisfied with?
Yes
No

I currently pay for my child's dental services through:

I prefer the following time of day for dental appointments for my child:

Do you currently have a hairstylist youare satisfied with?

Does your child's hair sylist currently come to your home?
Yes
No

What do you currently pay for your child's haircuts?

I prefer the following time of day for haircut appointments with my child:

I would prefer the following time of day for family/sibling counseling appointments:

I would pay for family/sibling counseling services through:

What would you be willing to pay per hour for counseling services?

Thank you for taking the time to complete the Jill's House family survey. We greatly appreciate your feedback.