Language
English (US)
Español
Arabic
Urdu
MUHSEN
MUHSEN is exploring expansion of its services to Australia and is eager to understand the needs of individuals with disabilities in your local communities. We warmly invite you to share your input through this survey. Your responses will help us assess local needs and tailor relevant services to better serve the community. This form is confidential and will only be reviewed by MUHSEN leadership to enhance services in your area. MUHSEN is a 501(c)(3) nonprofit organization based in the United States, serving families living with disabilities across multiple countries. We are dedicated to spreading awareness, creating accommodations, and fostering acceptance by supporting the unique needs of individuals with disabilities. Learn more about us at MUHSEN.org.
Begin
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: 0000-000-000.
Individual Information
I am a
*
Parent/Guardian or Caregiver
Individual with Special Needs
Other
Explain here..
Name
*
First Name
Last Name
Back
Next
Information of Individual with Special Needs
Name
*
First Name
Last Name
Age
*
birth - 5
6 - 12
13 - 17
18 - 24
25 - 39
40+
Gender
*
Male
Female
Prefer not to say
City
Zipcode/Postal Code
State/Territory
Please Select
Australian Capital Territory (ACT)
New South Wales (NSW)
Northern Territory (NT)
Queensland (QLD)
Tasmania (TAS)
South Australia (SA)
Victoria (VIC)
Western Australia (WA)
Diagnosis (select all that apply)
Attention-Deficit/Hyperactivity Disorder
Autism
Blindness
Cerebral Palsy
Deafness
Developmental Delay
Down Syndrome
Epilepsy
Hearing Impairment (hard of hearing)
Learning Disability
Muscular Dystrophy
Physical Disability
Speech Impairment
Other
School Placement (Select all that apply)
*
Mainstream Government/Public School
Special Needs Government/Public School
Independent/Private School
Islamic School - Full time
Islamic School - Weekend
Homeschool
High school Graduate
Adult Program
Does Not Apply
Other
Back
Next
Survey Questions
Name of your local Masjid
*
Zipcode/Postal Code
City
State/Territory
Please Select
Australian Capital Territory (ACT)
New South Wales (NSW)
Northern Territory (NT)
Queensland (QLD)
Tasmania (TAS)
South Australia (SA)
Victoria (VIC)
Western Australia (WA)
On a scale of 1 to 10, how would you rate your family member's acceptance in the Muslim community? (1-Poorly Accepting to 10 - Greatly Accepting)
*
1
2
3
4
5
6
7
8
9
10
Which supports would enhance participation from your Special Needs family member at the Masjid? (select all that apply)
Adult Life Skills Programs
Access to Programs and Classes
Accessibility
Braille Quran
Child Care Options
Closed Captioning/Visual Resources
Large Print Quran
Open House for families with Special Needs
Quiet Room
Sensory Supports (Light & Sound)
Sign Language
Support Groups
Weekend Schools
Youth Options
Other
Would you and/or your Special Needs family member like to attend a gathering to meet other families?
*
Yes
No
Maybe
Would you be interested in a caregiver/individual/sibling support group?
Yes
No
Maybe
Would you be interested in volunteering to help with MUHSEN's mission?
*
Yes
No
Maybe
How did you hear about Muhsen?
*
Referred by a friend/family
Masjid/Mosque Annoucement
Social Media (Instagram, Facebook)
Google search
Online advertisement
Local event
Convention
Other
Do you/your family member with a disability currently receive NDIS (National Disability Insurance Scheme) Funding
*
Yes
No
Do you/your family member with a disability receive any other type of government care funding?
*
Yes
No
If Yes, please state what type
Do you have any other questions or comments you would like to add?
Submit
Should be Empty: