We Need Your Input - HORIZONS OF HOPE

Who is filling out the form?

I am filling out the form for myself
I am filling out the form for someone else and I will be the contact person

If you are filling out the form for someone else what is your relation to the person interested in our program?

Name of Contact Person

First

Last

Email

Are you currently on the Self-Determination Program (SDP)

YES
NO

What challenges have you faced with finding services or programs? (Check all that apply)

Exclusion due to behavioral challenges
Lack of tailored activities or programs
Limited job opportunities or training
Difficulty finding trained aides

Other (Please specify)

Are there specific behavioral challenges you’d like addressed?

What types of activities and programs interest you? (Check all that apply)

Other types of activities and interests:

Are you interested in job training or employment opportunities?

YES
NO

If yes, what areas of work interest you? Check all that apply)

Office/Administative
Creative/Arts
Food Service
Janitorial

Other work interests

Do you currently have a one-on-one aide?

YES
NO

or is or

Does this aid work full-time or part-time?

Full-time
Part-time
Part-time but willing to work full-time

If yes, what support would you like your aide to receive? (Check all that apply)

Training on behavioral strategies
Guidance on daily activities
Ongoing communication with professionals (e.g. BCBA)

Other (Please specify):

Are there additional services or supports you’re looking for? Describe:

Thank You!

We appreciate your input and look forward to building a community where every journey begins with hope. If you have any questions, please contact us at: • Email: info@horizons-of-hope.org • Phone: 909-815-4615