Cove Family Survey - Twenty-One Senses

Are you a Cove School family? We are too!

We're doing market research to prepare for the launch of our start-up: a community that supports families with sensory-sensitive kids. Gathering information from families like yours will help ensure we're going in the right direction. As a thank you, we'll donate $1 to The Cove School for every survey filled out by a Cove family.

Name

First

Last

Email

Zip Code

# of Kids in the Family

With Sensory Sensitivities

Without Sensory Sensitivities

What's the maximum distance are you willing to travel for...

Therapy

To and From Cove	In town (<20 min)	Surrounding area (<40 min)	Pretty far (<hour)	Anywhere! (> hour)
To and From Cove	In town (<20 min)	Surrounding area (<40 min)	Pretty far (<hour)	Anywhere! (> hour)

Playdate

To and From Cove	In town (<20 min)	Surrounding area (<40 min)	Pretty far (<hour)	Anywhere! (> hour)
Activity with sensory interventions in place To and From Cove	Activity with sensory interventions in place In town (<20 min)	Activity with sensory interventions in place Surrounding area (<40 min)	Activity with sensory interventions in place Pretty far (<hour)	Activity with sensory interventions in place Anywhere! (> hour)

Social Activity

To and From Cove	In town (<20 min)	Surrounding area (<40 min)	Pretty far (<hour)	Anywhere! (> hour)
Activity with sensory interventions in place To and From Cove	Activity with sensory interventions in place In town (<20 min)	Activity with sensory interventions in place Surrounding area (<40 min)	Activity with sensory interventions in place Pretty far (<hour)	Activity with sensory interventions in place Anywhere! (> hour)

Extracurricular Activity

To and From Cove	In town (<20 min)	Surrounding area (<40 min)	Pretty far (<hour)	Anywhere! (> hour)
Activity with sensory interventions in place To and From Cove	Activity with sensory interventions in place In town (<20 min)	Activity with sensory interventions in place Surrounding area (<40 min)	Activity with sensory interventions in place Pretty far (<hour)	Activity with sensory interventions in place Anywhere! (> hour)

Activity with sensory interventions in place

To and From Cove	In town (<20 min)	Surrounding area (<40 min)	Pretty far (<hour)	Anywhere! (> hour)
To and From Cove	In town (<20 min)	Surrounding area (<40 min)	Pretty far (<hour)	Anywhere! (> hour)

For the rest of this survey, please tell us about one of your children.

You can fill out this survey again with another child in mind. Don't forget - we will donate $1 per survey completed!

Child's School Level

Tell us about your child's sensory needs. (Select the most common response per system.)

Visual (sights)

Sensory Seeking	Sensory Avoiding	Depends on the situation	Unaffected	Unsure
Sensory Seeking	Sensory Avoiding	Depends on the situation	Unaffected	Unsure

Auditory (sounds)

Sensory Seeking	Sensory Avoiding	Depends on the situation	Unaffected	Unsure
Interoception (internal) Sensory Seeking	Interoception (internal) Sensory Avoiding	Interoception (internal) Depends on the situation	Interoception (internal) Unaffected	Interoception (internal) Unsure

Olfactory (smell)

Sensory Seeking	Sensory Avoiding	Depends on the situation	Unaffected	Unsure
Interoception (internal) Sensory Seeking	Interoception (internal) Sensory Avoiding	Interoception (internal) Depends on the situation	Interoception (internal) Unaffected	Interoception (internal) Unsure

Gustatory (taste)

Sensory Seeking	Sensory Avoiding	Depends on the situation	Unaffected	Unsure
Interoception (internal) Sensory Seeking	Interoception (internal) Sensory Avoiding	Interoception (internal) Depends on the situation	Interoception (internal) Unaffected	Interoception (internal) Unsure

Tactile (touch)

Sensory Seeking	Sensory Avoiding	Depends on the situation	Unaffected	Unsure
Interoception (internal) Sensory Seeking	Interoception (internal) Sensory Avoiding	Interoception (internal) Depends on the situation	Interoception (internal) Unaffected	Interoception (internal) Unsure

Vestibular (body in space)

Sensory Seeking	Sensory Avoiding	Depends on the situation	Unaffected	Unsure
Interoception (internal) Sensory Seeking	Interoception (internal) Sensory Avoiding	Interoception (internal) Depends on the situation	Interoception (internal) Unaffected	Interoception (internal) Unsure

Proprioceptive (pressure on joints)

Sensory Seeking	Sensory Avoiding	Depends on the situation	Unaffected	Unsure
Interoception (internal) Sensory Seeking	Interoception (internal) Sensory Avoiding	Interoception (internal) Depends on the situation	Interoception (internal) Unaffected	Interoception (internal) Unsure

Interoception (internal)

Sensory Seeking	Sensory Avoiding	Depends on the situation	Unaffected	Unsure
Sensory Seeking	Sensory Avoiding	Depends on the situation	Unaffected	Unsure

Does your child participate in any enrichment programs? (Select all that apply.)

Sports

No	At Cove	Outside of Cove - Special Needs Focused	Outside of Cove - With Supports	Outside of Cove - With No Supports
No	At Cove	Outside of Cove - Special Needs Focused	Outside of Cove - With Supports	Outside of Cove - With No Supports

Scouts

No	At Cove	Outside of Cove - Special Needs Focused	Outside of Cove - With Supports	Outside of Cove - With No Supports
No	At Cove	Outside of Cove - Special Needs Focused	Outside of Cove - With Supports	Outside of Cove - With No Supports

Art

No	At Cove	Outside of Cove - Special Needs Focused	Outside of Cove - With Supports	Outside of Cove - With No Supports
Art No	Art At Cove	Art Outside of Cove - Special Needs Focused	Art Outside of Cove - With Supports	Art Outside of Cove - With No Supports

Music

No	At Cove	Outside of Cove - Special Needs Focused	Outside of Cove - With Supports	Outside of Cove - With No Supports
Art No	Art At Cove	Art Outside of Cove - Special Needs Focused	Art Outside of Cove - With Supports	Art Outside of Cove - With No Supports

Dance

No	At Cove	Outside of Cove - Special Needs Focused	Outside of Cove - With Supports	Outside of Cove - With No Supports
Art No	Art At Cove	Art Outside of Cove - Special Needs Focused	Art Outside of Cove - With Supports	Art Outside of Cove - With No Supports

Social programs

No	At Cove	Outside of Cove - Special Needs Focused	Outside of Cove - With Supports	Outside of Cove - With No Supports
No	At Cove	Outside of Cove - Special Needs Focused	Outside of Cove - With Supports	Outside of Cove - With No Supports

Other

No	At Cove	Outside of Cove - Special Needs Focused	Outside of Cove - With Supports	Outside of Cove - With No Supports
No	At Cove	Outside of Cove - Special Needs Focused	Outside of Cove - With Supports	Outside of Cove - With No Supports

In general, how successful is your child in participating in enrichment programs?

Very successful	Fairly successful	It's a struggle	Not at all	Not applicable
Very successful	Fairly successful	It's a struggle	Not at all	Not applicable

Outside of Cove - Special Needs Focused

Very successful	Fairly successful	It's a struggle	Not at all	Not applicable
At Cove Very successful	At Cove Fairly successful	At Cove It's a struggle	At Cove Not at all	At Cove Not applicable

Outside of Cove - With Supports

Very successful	Fairly successful	It's a struggle	Not at all	Not applicable
At Cove Very successful	At Cove Fairly successful	At Cove It's a struggle	At Cove Not at all	At Cove Not applicable

Outside of Cove - With No Supports

Very successful	Fairly successful	It's a struggle	Not at all	Not applicable
Outside of Cove - With No Supports Very successful	Outside of Cove - With No Supports Fairly successful	Outside of Cove - With No Supports It's a struggle	Outside of Cove - With No Supports Not at all	Outside of Cove - With No Supports Not applicable

Tell us about a social or enrichment experience where your child was successful. What was the experience? What do you think helped make it successful?

Which of the following is most helpful in creating a successful outing for your child? Select only one response in each category.

Sensory Inputs

The environment is built around sensory sensitivities
Caregiver provides sensory interventions
Not Applicable

Integration Model

Child participates with other sensory sensitive kids
Child is integrated with all kinds of kids
Not a factor in success

Organization Model

Activity is grouped by age-level
Activity is grouped by skill or comprehension level
Not a factor in success

Adult Leader

Is a good temperament match with your child
Has been professionally trained
Not a factor in success

Do you think the things that help your child be successful are unique to them?

Yes, my child has a unique set of challenges
No, other children with sensory sensitivities would also benefit
No, all children could benefit

Tell us about a social or enrichment experience that was unsuccessful. What was the experience? What went wrong? How did your child react?

What does it look like when your child is unsuccessful in a social or enrichment activity? (Select all that apply.)

He/she is deregulated during the activity
He/she is deregulated for some period of time after the activity
He/she tries to participate, but is unable to successfully
He/she wants to participate but is left out
He/she refuses to participate
Adult guidance is lacking
The adult in charge lacks knowledge of how to successfully help
The adult in charge is not a good match with my child

Do you think the things that impede your child from being fully successful in an enrichment experience are unique to him/her?

Yes, my child has a unique set of challenges
No, other children with sensory sensitivities would also be tripped up
No, all children are affected by these factors to some degree

What could be done to improve a situation that is not going well? (Select all that apply.)

Making sensory interventions available
Assign him/her a buddy
Create lower adult to child ratios
Create more purposeful integrations
Make a quiet space available
Finding the same activity somewhere else more conducive to our needs
A different adult leading the activity

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