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  • Begin

  • Format: (000) 000-0000.

  • Individual Information

  • I am a*

  • Information of Individual with Special Needs

  • Age*
  • Gender*
  • Diagnosis (select all that apply)*
  • School Placement (Select all that apply)*

  • Survey Questions

  • 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)*
  • Which supports would enhance participation from your Special Needs family member at the Masjid? (select all that apply)
  • Would you and/or your Special Needs family member like to attend a gathering to meet other families?*
  • Would you be interested in a caregiver/individual/sibling support group?*
  • Would you be interested in volunteering to help with MUHSEN's mission?*
  • How did you hear about Muhsen?*
  • Should be Empty: