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Name
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First Name
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birth - 5
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25 - 39
40+
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Vatican City
Venezuela
Vietnam
British Virgin Islands
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US Virgin Islands
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Western Sahara
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Other
Country
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)
*
Public School
Private Therapy Center
Homeschool
Islamic School - Full Time
Islamic School - Weekend
Graduate
Adult Program
Does not apply
Other
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Survey Questions
Name of your local Masjid
*
City
*
State/Province
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
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Illinois
Indiana
Iowa
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Kentucky
Louisiana
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Maryland
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Michigan
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Ohio
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Rhode Island
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Texas
Utah
Vermont
Virginia
Washington
West Virginia
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Canada - Quebec
Canada - Ontario
Canada - Fredericton
Canada - Manitoba
Canada - Saskatchewan
Canada - Alberta
Canada - British Colombia
Canada - Yukon
Canada - Northwest Territories
Canada - Nunavut
Canada - Newfoundland and Labrador
Canada - Nova Scotia
Others
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*
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United States
Canada
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
On a scale of 1 to 10, how would you rate your family member's acceptance in the Muslim community? (1- Extremely Low Acceptance, 10 - Highly Accepted)
*
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
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