Pre-Session Social Club Questionnaire

Pre-session Social Club Questionnaire

Asperger Syndrome Foundation is planning a Social Club for adults (18-25yrs) with Asperger Syndrome in Central London. We want to provide an opportunity to socialize and make friends through shared interests. We would be grateful if you would answer the following questions.

Your time is appreciated.

Full name:
Full Address:
Email:
Mobile phone number:
Daytime phone number:
Gender:
Age:
Person with Asperger Syndrome
(please circle which one is applicable to you) / a. Formally diagnosed
b. Self-diagnosed
Age of Diagnosis:
Living circumstances (please circle which one is applicable to you) / a. Live with family
b. Live with friends
c. Supported housing
d. Independently
e. Other:
Educational History Status (please circle which one is the highest level of education you have completed) / a. Incomplete secondary school
b. Completed secondary school
c. Incomplete further education college
d. Completed further education college
e. Incomplete University
f. Completed University
g. Higher than University (post graduate)
Which type of education have you received? (please circle one of the options) / a. Specialist
b. Mainstream
c. Both Specialist and Mainstream
Employment Status (please circle which one is applicable to you) / a. Unemployed
b. Studying (fulltime/part-time)
c. Working part-time/casual
d. Working full time
e. Volunteer
Do you have any health issues or physical impairment? / □ No
□ Yes
If yes please specify:
Do you have any learning difficulties? / □ No
□ Yes
If yes please specify:
The planned Social Club would be in Central London. Would you be able to travel to the venue? (You would need to provide your own transport) / □ No
□ Yes
Lunch and refreshments will be provided. Do you have any food allergies? / □ No
□ Yes
If yes please specify:
Do you use a support worker/carer on a day to day basis? / □ No
□ Yes
If yes please specify:
Below are some ideas for the Social Club activities. Please rate (by preference) each from 1-3 to indicate your interest in each topic:
Communication and Body Language / 1 – Not Interested
2 – Interested
3 – Very Interested
Friends and Relationships / 1 – Not Interested
2 – Interested
3 – Very Interested
Couples Support/Relationship Issues / 1 – Not Interested
2 – Interested
3 – Very Interested
Practising Social Skills / 1 – Not Interested
2 – Interested
3 – Very Interested
Self-Awareness / 1 – Not Interested
2 – Interested
3 – Very Interested
Learn about Asperger Syndrome / 1 – Not Interested
2 – Interested
3 – Very Interested
Finances / 1 – Not Interested
2 – Interested
3 – Very Interested
Anger Management / 1 – Not Interested
2 – Interested
3 – Very Interested
Parent and Carer Support / 1 – Not Interested
2 – Interested
3 – Very Interested
Employment and Work Issues / 1 – Not Interested
2 – Interested
3 – Very Interested
Discussion Groups around specific interests / 1 – Not Interested
2 – Interested
3 – Very Interested
Independent Living Skills (public transport, eating in public, using shops, etc) / 1 – Not Interested
2 – Interested
3 – Very Interested
Increasing social activities and interaction / 1 – Not Interested
2 – Interested
3 – Very Interested
Other ideas (please give us your suggestions)
Please circle the option you prefer? / Weekday
1 – Daytime
OR
2 – Evening
Weekend (only daytime)
1 – Saturday
OR
2 – Sunday
What time of day is best for you?

Please use the box below to give further details about whether you would attend any Social Club sessions provided and if not: please give reasons why you would not attend.Thank you for your time.