Name
*
First Name
Last Name
Email
*
example@example.com
Back
Next
Section one focuses on caregiver strain, a commonly used measure for caregivers of all types; please answer how you experienced each of the following prior to working with Undivided and after Undivided. If you have specific examples of how Undivided has been supportive for a given topic, please include.
Back
Next
My sleep is disturbed (for example: The child I care for requires my assistance after bedtime and before 6 a.m.)
Prior to working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
After working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
How has Undivided impacted this?
Caring for my child negatively impacts other aspects of my life (for example: Personal relationships are negatively impacted because of the time I spend caring for my child)
Prior to working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
After working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
How has Undivided impacted this?
Caring for my child is a physical strain (for example: Ambulatory care; child purposely or accidentally inflicts physical harm on parents)
Prior to working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
After working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
How has Undivided impacted this?
Caring for my child feels confining (for example: Caring for my child restricts free time or social time beyond that of parents with typically developing children)
Prior to working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
After working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
How has Undivided impacted this?
Caring for my child requires significant family adjustments (for example: Caring for my child disrupts my routine or changes individual responsibilities)
Prior to working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
After working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
How has Undivided impacted this?
Personal plans have to change to take care of my child (for example: I had to turn down a job; I cannot keep plans)
Prior to working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
After working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
How has Undivided impacted this?
Other responsibilities have taken a back seat due to caring for my child (for example: other family members' needs or work)
Prior to working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
After working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
How has Undivided impacted this?
There have been emotional adjustments (for example: severe arguments about caregiving)
Prior to working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
After working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
How has Undivided impacted this?
Some behavior is upsetting (for example: The child I care for often has behavioral challenges)
Prior to working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
After working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
How has Undivided impacted this?
It's upsetting to me that my child's future is uncertain
Prior to working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
After working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
How has Undivided impacted this?
There have been work adjustments (for example: I have to take time off for caregiving duties)
Prior to working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
After working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
How has Undivided impacted this?
Caring for my child creates financial strain
Prior to working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
After working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
How has Undivided impacted this?
I feel completely overwhelmed (for example: I do not feel that I am caring for my child properly; I do not know the next step)
Prior to working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
After working with Undivided
*
Yes, on a regular basis
Yes, sometimes
No, or rarely
How has Undivided impacted this?
Back
Next
Section two focuses on how your employment has been impacted by your caregiving responsibilities.
Your current employment status
*
I am employed full-time
I have part-time employment
I am a full-time caregiver
If you left the workforce, indicate why below:
To accommodate my caregiving responsibilities
For reasons unrelated to caring for my child
Back
Next
I am completing the following as
*
Myself prior to becoming a full-time caregiver
On behalf on another guardian in my household
How many hours per month do you spend learning or researching how to support your child? (understanding accommodations, specialists, providers, IEP goals)
Prior to working with Undivided
*
0-2 hours
3-6 hours
7-10 hours
11+ hours
After working with Undivided
*
0-2 hours
3-6 hours
7-10 hours
11+ hours
How has Undivided impacted this?
How many times per month do you need to take unplanned time off from work to care for your child?
Prior to working with Undivided
*
Not at all
1-3 occurrences
4-6 occurrences
7+ occurrences
After working with Undivided
*
Not at all
1-3 occurrences
4-6 occurrences
7+ occurrences
How has Undivided impacted this?
How many times per month have you missed deadlines or appointments at work to accommodate your child's needs?
Prior to working with Undivided
*
Not at all
1-3 occurrences
4-6 occurrences
7+ occurrences
After working with Undivided
*
Not at all
1-3 occurrences
4-6 occurrences
7+ occurrences
How has Undivided impacted this?
How many days per month do you feel overwhelmed?
Prior to working with Undivided
*
A few days
About half
More than half
Almost every day
After working with Undivided
*
A few days
About half
More than half
Almost every day
How has Undivided impacted this?
How many days per month do you feel exhausted at work?
Prior to working with Undivided
*
A few days
About half
More than half
Almost every day
After working with Undivided
*
A few days
About half
More than half
Almost every day
How has Undivided impacted this?
Back
Next
Section three focuses on how Undivided has assisted you economically. If you have specific examples of how Undivided has been supportive for a given topic, please include.
Back
Next
Undivided has assisted my family in accessing, receiving and/or increasing:
Services, supports, and/or budget for Regional Center and/or Self-Determination Program
*
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
If applicable, what is the estimated $ value of acquired or additional resource?
IHSS and/or Medi-Cal benefits, services, trainings, approved hours, and/or appeals
*
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
If applicable, what is the estimated $ value of acquired or additional resource?
Reimbursements, coverage, or appeals from private insurance
*
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
If applicable, what is the estimated $ value of acquired or additional resource?
Services provided through the school district (e.g. speech, OT, counseling, 1:1 academic time, etc.)
*
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
If applicable, what is the estimated $ value of acquired or additional resource?
Back
Next
Section four focuses on how Undivided the platform specifically has impacted you and your family.
Back
Next
Having all my child's documents in one place (the Undivided digital binder) reduces my stress.
*
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
Having one place to ask all questions (Undivided) reduces my stress.
*
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
Having access to an Undivided Navigator has reduced my stress.
*
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
My family as a whole is better off as a result of having access to Undivided.
*
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
My child is better off as a result of having access to Undivided.
*
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
Having access to Undivided has made me a more effective parent.
*
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
Having access to Undivided has made me more productive at work.
*
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
Every parent of a child with disabilities should take advantage of Undivided.
*
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
Back
Next
Section five provides baseline information of when services were acquired regardless of whether Undivided played a part or not.
Any documents uploaded will be sent to your Navigator, and they will add them to your digital binder.
All information will remain confidential, and any use of the information or content will be aggregated and anonymized.
Back
Next
If convenient, please upload your first IFSP from the Regional Center
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please provide approximate date of IFSP if applicable:
If you are unsure how to answer, indicate one of the following:
I don't know where it is, see approximate date below
I did not receive Regional Center Early Intervention services
If convenient, please upload your first Regional Center IPP
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please provide approximate date of IPP if applicable:
If you are unsure how to answer, indicate one of the following:
I don't know where it is, see approximate date below
I do not receive Regional Center services
If convenient, please upload your Medi-Cal Notice of Action
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please provide approximate date of Medi-Cal NOA if applicable:
If you are unsure how to answer, indicate one of the following:
I don't know where it is, see approximate date below
I do not receive Medi-Cal services
If convenient, please upload your IHSS Notice of Action
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please provide approximate date of IHSS NOA if applicable:
If you are unsure how to answer, indicate one of the following:
I don't know where it is, see approximate date below
I do not receive In-Home Supportive Services
If convenient, please upload your first IEP
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please provide approximate date of first IEP if applicable:
If you are unsure how to answer, indicate one of the following:
I don't know where it is, see approximate date below
My child does not have an IEP
Submit
Should be Empty: