1840 Homewood Ave. Williamsport, PA 17701-3935 Phone: 570-360-5035 Email: info@canaccess.org Website: www.canaccess.org

Individual and Family Needs Questionnaire

Congregation: ___________________________________

Date: ___/___/___

Our congregation seeks to be a welcoming, caring community for all who would worship or associate with us. Many of us live with physical, sensory, psychiatric (emotional), or intellectual disabilities. We want to become aware of any barriers in our congregation’s structures, communication, or attitudes that hinder full participation in our life together.

Our goal is to achieve the standards outlined by the Congregational Accessibility Network (CAN) in its “Congregational Assessment Survey.” That survey can be found online at www.canaccess.org. CAN is an international interfaith program to promote the inclusion of persons with disabilities in faith communities.

The survey groups accessibility issues into the following broad categories, which this questionnaire will follow:

Mobility—the physical characteristics of the building and grounds which either support or hinder access for all.

Hearing, Language and Vision—issues related to hearing and vision.

Support—the attitudes and choices of the congregation which affect how well we include individuals and families living with physical, emotional, sensory, and intellectual disabilities.

Please help us by filling out this questionnaire for yourself and all members of your immediate family.
Return to: _________________(place/person), by: ___/___/___ (date).

The personal information you share will be treated with respect and shared only with:

_____________________________

Individual and Family Needs Questionnaire

1.	If you or a member of your family live with any of the following, please indicate below.

☐ Use a wheelchair

☐ Use a cane or walker

☐ Other mobility challenge(s): _____________________________________

☐ Hearing loss

☐ Other auditory challenge(s): ________________________________

☐ Vision loss

☐ Other vision-related challenge(s): ________________________________

☐ Allergies: ___________________________________________________

☐ Alzheimer's

☐ Anxiety

☐ Attention deficit disorder (ADD or ADHD)

☐ Autism spectrum disorder: ____________________________

☐ Bipolar disorder

☐ Chemical sensitivity

☐ Depression

☐ Developmental disabilities
☐ Down syndrome

☐ Fetal Alcohol spectrum disorder

☐ Learning disability

☐ Obsessive compulsive disorder (OCD)

☐ Panic attacks

☐ Schizophrenia
☐ Sensory issues:______________________________________

☐ Other: ____________________________________________
If you checked any boxes in No. 1, please answer questions 2-6; if not, skip to No. 7
2.	Are other people in the congregation aware of these challenges?

☐Yes ☐No

3.	Are you and your family comfortable having others aware of these challenges?

☐Yes ☐No
Please explain (if you wish): __________________________________
4.	Do you and your family feel welcomed, accepted, and included in the congregation?

☐ Always ☐ Usually ☐ Sometimes ☐ Never

Please explain (if you wish): ______________________________________

5.	What would make it easier to participate in congregational activities such as worship, choir, educational activities, fellowship meals, and youth group? (Check all that apply.)

Mobility
☐ Access to the podium and platform area of the sanctuary
☐ Permission to walk, stand, or sit (other than in the pew) during worship service
☐ Reserved accessible parking spaces
☐ Restrooms accessible to wheelchair users
☐ Transportation to congregational activities
☐ Wheelchair seating spaces in the sanctuary (not in the aisles)
☐ Other needs _____________________________________________

Hearing, Language and Vision
☐ American Sign Language interpreter
☐ Other sign language interpreter _____________________________
☐ Assistive Listening Devices
☐ Improved lighting in worship area
☐ Large-print bulletins and song books
☐ Other needs _____________________________________________

Support

☐ Adaptations in educational curriculum for persons with intellectual disabilities.

☐ Allergy awareness and willingness to adapt for needs of affected individuals

☐ Assistance in religious education and/or youth group activities

☐ Awareness of effects of chemicals and fragrances on sensitive individuals

☐ Educational events related to disability/mental illness
☐ Financial assistance
☐ Friend or companion in congregation for myself or family member
☐ Inclusion in worship activities
☐ Increased understanding by congregational leaders
☐ Increased understanding by congregational members

☐ Information about community resources on mental illness and disabilities

☐ Invitation to attend congregational functions

☐ Library resources
☐ Opportunity to serve within the congregation
☐ Respite care for family member

☐ Sermons related to disability/mental illness
☐ Support group (type needed) ___________________________________
☐ Other support needs: __________________________________________

6.	How would you and your family members like to contribute to the life of the congregation?

__________________________________________________________________

a. Are you currently able to participate in this way? ☐Yes ☐No

b. If not, what would make this possible?

7.	I am aware of persons in the congregation who live with disabilities (including mental illness). ☐Yes ☐No

8.	I believe it is a part of our congregation's mission to welcome and provide fellowship and assistance to people who have disabilities (including mental illness).

☐ Strongly agree ☐ Agree ☐ Unsure ☐ Disagree ☐ Strongly disagree

9.	I believe our congregation should support individuals and families experiencing mental illness (such as anxiety disorders, bipolar, depression, and schizophrenia) in the same way we support those experiencing other illnesses.

☐ Strongly agree ☐ Agree ☐ Unsure ☐ Disagree ☐ Strongly disagree

10.	I find it helpful when those living with mental illness or other disabilities share their stories with our congregation.

☐ Strongly agree ☐ Agree ☐ Unsure ☐ Disagree ☐ Strongly disagree

Thank you for taking the time to share this important information with us! If you are willing, please sign your name below. Doing so will help us as we seek to grow in mutual support. However, we know that trust cannot be forced, and we will accept and listen carefully to what you’ve shared whether signed or anonymous. If you would like to be contacted about something related to this questionnaire, please provide your phone number as well.

Name: _________________________________________

Please contact me at: __________________________________(phone or email optional)

We welcome any additional thoughts and comments! Please write them below or on the back of this page.

1840 Homewood Ave. Williamsport, PA 17701-3935 Phone: 570-360-5035 Email: info@canaccess.org Website: www.canaccess.org