The following questionnaire is designed to enable parents to share information
about various health and therapy providers with other parents. The information
you provide will be supplied to families seeking similar services. This
information will be provided as a "family recommendation" and not as an SCAS
recommendation.
As many families know, it is often difficult to find a dentist or private
occupational therapist who knows about or understands autism. The goal of this
family questionnaire is to help other families find those specialists more
quickly. Your information will assist other families in learning if specialists
have ever worked with someone with autism and if other families would recommend
them.
Thanks for taking time to help other families find the support people they
need. If you are looking for a service provider, please be sure to call SCAS at
800-438-4790. Together, we can solve the puzzle!
1. What therapies are you currently using for your child?
Type of Therapy/Treatment:
Provider:
Phone:
Address:
City:
State:
Zip:
Recommend to others?
Yes
|
No
Approximate cost:
Type of Therapy/Treatment:
Provider:
Phone:
Address:
City:
State:
Zip:
Recommend to others?
Yes
|
No
Approximate cost:
Type of Therapy/Treatment:
Provider:
Phone:
Address:
City:
State:
|
Zip:
Recommend to others?
Yes
|
No
Approximate cost:
Type of Therapy/Treatment:
Provider:
Phone:
Address:
City:
State:
|
Zip:
Recommend to others?
Yes
|
No
Approximate cost:
2. Who is your physician?
Name:
Phone:
Address:
City:
State:
|
Zip:
Recommend to others?
Yes
|
No
3. Who is your dentist?
Name:
Phone:
Address:
City:
State:
|
Zip:
Recommend to others?
Yes
|
No
4. Outside of school, who do you use for the following:
Occupational Therapy:
Name:
Phone:
Address:
City:
State:
|
Zip:
Recommend to others?
Yes
| No
Physical Therapy:
Name:
Phone:
Address:
City:
State:
|
Zip:
Recommend to others?
Yes
| No
Speech Therapy:
Name:
Phone:
Address:
City:
State:
|
Zip:
Recommend to others?
Yes
| No
Psychiatrist or Psychologist:
Name:
Phone:
Address:
City:
State:
|
Zip:
Recommend to others?
Yes
| No
5. What school district do you live in?
6. What school does your child attend?
7. What type of class placement does your child have?
8. Please list any comments that may help other parents:
