Appendix A

Block 1: Demographics:
Gender: Male Female Age: ______________ Ethnicity: Caucasian African American Latino/Hispanic Native American/Pacific Islander Asian Other:________________ Number of family members living in home:__________________________ Marital status: Married Single/never married Divorced Separated

Relationship to child diagnosed with autism (on the autistic spectrum): Parent Step Parent Legal guardian Grandparent

Block 2: Treatment information:

1. Did you seek treatment/support for your child when he/she was diagnosed on the autistic spectrum? Yes No (survey stops here) 2. Briefly describe what resources you sought for your child and or family:_________________________________________________________________ __________ 3. Which resources does your child receive? Please select all that apply: ___IEP ___Occupational therapy ___Speech Therapy ___Individual therapy ___Family Therapy Other____________ Other____________

4. Where does your child receive treatment? (select all that apply)

In home

At school

Private practice

Outpatient facility

5. How long has your child been in treatment? 6. Do any other members of your family receive mental health services or support? 6B. Please briefly describe other family members services or support received.

Block 3: Family Satisfaction: If answered YES family member will see question #b, if answered NO family will skip #b and move onto next question #.
1. Does your childs behavior affect your family functioning? 1b. How does your childs behavior affect your family functioning?

2. Has your relationship with your child changed? 2b. How has your relationship with your child changed?

3.Would you like your relationship with your child to change? 3b. How would you like your relationship with your child to change?

4. Has your relationship with your partner changed (N/A answer choice) 4b. How has your relationship with your partner changed?

5. Would you like your relationship with your partner to change. (N/A answer choice) 5b. How would you like your relationship with your partner to change?

6. Have you noticed a change in your self-confidence/selfimage? 6b. What changes have you noticed in your self-confidence/self image?

7. Have you notice a change in how your Family copes with new routines 7b. What change(s) have you noticed in how your family copes with new routines?

8. Have you noticed a change in how your family copes with change? 8b. what change have you noticed in how your family copes with change?

9. Have you noticed a change in your familys social life? 9b. How has your familys social life changed?

10. Have you noticed a change in interactions between family members? 10b. Briefly describe how interactions between family members has changed.

11. Briefly describe something your family can do now that you did not feel was possible before.

12. Briefly describe an accomplishment your family has made.

13. Draw what happiness looks like for your family.