Please use the form below to create a new question you would like added to any of our current questionnaires (short, standard, or extended) or to your custom questionnaire.  This form will help you design one or two questions.  If you have more questions to add, then return to this form and submit additional questions separately.

Designing questions can be challenging as there are often unforeseen parent responses, but we will help you with this and customize your question(s) and response(s) exactly as you would like.  If this form does not address your needs, you have any questions, or you are unclear about the directions below, please use our contact form.  Once you submit this form, we will contact you to work out any needed details and provide a quote for creating the question(s).

Tips for creating new questions:

• The "primary question" is the first question you ask, such as: “Has Johnny undergone surgery?”
• If you like, you may create a "secondary question" based on a client's response to the primary question.  For example, if the parent said Johnny had undergone surgery, you could ask one or more additional questions such as: "How old was Johnny when he underwent surgery?" and/or "What kind of surgery did Johnny undergo?"
• Please note our forms personalize most questions.  When writing your question(s) and response(s) below, please use "he/she" or "his/her" type references so we know where to input the child's gender appropriately.  You may also use the child's first name within the question, which you may identify with a "CN," or the person's name filling out the form with a "PN."  (For the sake of simplicity, in the remainder of this form the person filling out the questionnaire will be referred to as the "parent" and the client as the "child.")

If the options presented on this form do not meet your needs (e.g., you require multiple secondary questions), please try to describe how you would like the overall set of questions to work in the space provided below.  You may also use that field to request desired modifications to an existing question on one of the current forms.

Please begin by entering the information below (all fields required) so that we may contact you with a quote or questions once we have evaluated your submission.

Title: Select Ms. Mrs. Mr. Dr.

First Name:

Last Name:

Email Address:

Formatting of the responses requires considering all possible ways, or combination of ways, a client could respond.  Please specify, to the best of your ability, exactly how you would like the responses to read, including any particular quotes, client's name, parent's name, etc.  We have the ability to concatenate responses, so if a person chooses multiple responses we can automatically place commas between each of their responses and add an "and" before the last response.  It is also important you carefully consider exactly where you want commas, periods, or quotes within the response.  Please specify how you would like responses to read and, ideally, give examples of every possible outcome.  (You may use our 3-page demo form to get ideas of how responses may be formatted.)

We can color code the client's responses as black (for normal/typical responses) or blue for abnormal responses/issues.  We can also code blue text if the response falls outside a certain range (such as if certain answers are selected within a drop down menu or a number is typed into a response).  In entering your responses below, enclose any portion of a particular response with *asterisks* that you want to appear in blue text.

Please add any other instructions or comments about your new question(s) not covered above by this form.