Rainbow Babies & Children's Hospital / Monarch Center for Autism at Bellefaire JCB - Early Intervention Survey for Autism Spectrum Disorders
Answers marked with a * are required.
1.
Introduction
An escalating number of children under the age of 3 are being diagnosed with Autism Spectrum Disorders (ASD). In an effort to better serve these children and their families, Monarch Center for Autism and Rainbow Babies & Children's Hospital are conducting a survey to identify early intervention needs. Your participation is greatly appreciated. Please take a few minutes to answer the questions below.
1.
Who was the first person to notice delays and/or express concern about your child's development?
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Parent/Caregiver
Pediatrician
Family Member
Child Care Provider/Teacher
Other (Please Specify)
2.
If you specified "Family Member" as the answer to Question No. 1, is the family member a teacher or health care provider?
Yes
No
Other (Please Specify)
3.
How old was your child when these delays/concerns initially began?
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0-6 months
7-12 months
13-24 months
2-3 years
over 3 years
4.
At what age was your child diagnosed?
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5.
What is your child's diagnosis?
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Autism
Asperger's Syndrome
Pervasive Developmental Disorder (PDD or PDD-NOS)
Rett Syndrome
Childhood Disintegrative Disorder (CDD)
Other (Please Specify)
6.
Who diagnosed your child?
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Primary Care Pediatrician
Developmental Pediatrician
Neurologist
Child Psychologist/Psychiatrist
Other (Please Specify)
7.
Do you have any other children diagnosed with an Autism Spectrum Disorder?
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Yes
No
8.
What services, if any, were recommended for you and/or your child? (indicate all that apply)
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Speech Language Therapy
Occupational Therapy
Physcial Therapy
Social Skills Group
Parent Education/Support Group
Home-Based Services
ABA
Floor Time
Dietary Interventions (e.g., GFCF)
Medication Management
Other (Please Specify)
9.
If your child was diagnosed with an ASD and was under the age of three, would you have been interested in attending a center-based program that offered the services listed in Question No. 8?
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Yes
No
10.
Please rate the following direct services as far as whether they would have been/would be helpful for your child when he/she was under the age of 3 years.
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Yes
No
Maybe
ABA home-based programming
ABA school-based programming
Behavior management assistance (e.g., toilet training, school preparation, behavioral outbursts, sleep issues)
Comprehensive evaluation/diagnosis by specialist
Counseling for self or other parent
Counseling for family
Preschool (non-ABA or mixed ABA and other fields)
Recreational programming (e.g., swimming, tumbling, dancing)
Social Skills programs and activities
Therapy: home-based, individual: Speech and Language
Therapy: home-based, individual: Occupational Therapy
Therapy: home-based, individual: Floor Time
Therapy: home-based, individual: ABA
11.
Please select any of the following information/services that you feel would be helpful to the family of a child under the age of 3.
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Advocate for child
Case management
Dietary and nutritional therapies
Family activities, games, educational toys and activities (online or other)
IEP and other school-age information
IFSP support and advocacy
Information for newly diagnosed children
Insurance information
Legal information (e.g., special education law)
Lending library (e.g., books, CDs, DVDs)
National and/or regional organizations/resources
One-on-one parent mentoring or parent support group
Parent information sessions/workshops
Referral service for medical, dental and other area providers
Respite care
Schools/summer camps
Sibling training and supports
Technology (e.g., hardware, software, equipment)
Upcoming events in your area
Alternative or holistic therapies
Other (Please Specify)
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