Family Survey - Early Intervention

This is a survey for families receiving Early Intervention services. Your responses will help guide efforts to improve services and results for children and families. For each statement below, please select one of the following response choices: very strongly disagree, strongly disagree, disagree, agree, strongly agree, very strongly agree. You may skip any item that you feel does not apply to your family.

Family-Centered Services

  1. I was offered help I needed, such as child care or transportation, to participate in the Individualized Family Service Plan (IFSP) meeting(s).

  2. I was asked whether I wanted help in dealing with stressful situations.

  3. I was given choices concerning my family's services and supports.

  4. My family's daily routines were considered when planning for my child's services.

  5. I have felt part of the team when meeting to discuss my child.

  6. The services on our IFSP have been provided in a timely way.

Please note that this is a demo version. Some questions have been deliberately omitted.

48. State of Residence

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

49. Child's Age at Time of Survey Completion

Birth to 1 year
1 - 2 years
2 - 3 years
Over 3 years

50. Child's Age When First Referred to Early Intervention

Birth to 1 year
1 - 2 years
2 - 3 years

51. Child's Race / Ethnicity

White
Black or African-American
Hispanic or Latino
Asian or Pacific Islander
American Indian or Alaskan Native
Multi-racial

For Office Use Only

52. Program Code