1. Indicate your relationship to the person:____ Parent ______ Instructor

_____Therapist/Residential Staff _______ (Other)

2. How long have you known the person?____ Years ___ Months

3. Do you interact with the person daily? ____ Yes ___ No

4. In what situations do you usually interact with the person?

____Meals _____Academic training

____Leisure _____ Work or vocational training

____Self-care____________(Other)