FAMILY QUESTIONNAIRE | Bridgelinknv.org

Serving all of Northern Nevada's

Special Needs Families

Bridgelink Family Questionnaire

Please fill out this form to the best of your ability so that we can assist you and your family as much as possible. The more we know, the more we can help. Please fill out separate forms for each special needs individual.

Primary caregiver's first name *

Other Parent, Caregiver or Guardians

Phone

Full Name of Child or Adult with Special Needs *

Primary caregiver's last name *

Full Address *

Email *

Birthday *

What kind of help or assistance are you looking for from Bridgelink if any at this time?

Additional Notes

Diagnosis (Choose all that apply)

Learning Disability

Physical Limitations

Vision Impairment

Hearing Impairment

Mental Illness

Down Syndrome

Epilepsy

Cerebral Palsy

Muscular Dystrophy

Alzheimer's Disease / Dementia

Parkinson's Disease

Dystonia

ALS ( Lou Gehrig's Disease)

Huntinton's Disease

Neuromuscular Disease

Mutiple Sclerosis

Stroke

Specific Learning Disability

Other (please explain in the section "additional info")

Tell us about your child or adult including attending school, work program, primary place of residence or other important information.

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Bridgelink's Family Questionnaire

Please fill out this form to the best of your ability so that we can assist you and your family as much as possible. The more we know, the more we can help. Please fill out separate forms for each special needs individual.

Primary caregiver's first name *

Primary caregiver's last name *

Street Address*

City *

State *

Zip Code *

Primary Caregiver's Phone

Email *

What kind of help or assistance are you looking for from Bridgelink at this time?

Tell us about your child or adult, including attending school, work program, primary place of residence or other important information.

Please let us know if there are any areas that you would like more information on. IE; Resources, Specific Classes, Meetups/Support Groups, etc.

Is there anything else you need assistance with?

Other Parent, Caregiver or Guardians (Full name)

Full Name of Child or Adult with Special Needs *

Birthday ( of child or adult with special needs) *

Does your special needs child have any siblings under 18? *

Diagnosis (Choose all that apply)

Learning Disability

Physical Limitations

Vision Impairment

Hearing Impairment

Mental Illness

Down Syndrome

Epilepsy

Cerebral Palsy

Muscular Dystrophy

Alzheimer's Disease / Dementia

Parkinson's Disease

Dystonia

ALS ( Lou Gehrig's Disease)

Huntinton's Disease

Neuromuscular Disease

Mutiple Sclerosis

Stroke

Specific Learning Disability

Speech Delay

Other (please explain in the section "additional info")

Please include a copy of the IEP or 504 if available or needed

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How did you hear about Bridgelink?

Would you like to recieve newsletters from Bridgelink?

Additional Notes

Bridgelink's Privacy Policy

I have read and agree with Bridgelink's Privacy Policy

Thank you for submitting!

We will get back to you soon.

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