DDS Family Survey

Directions:

On the following pages, please select the number that best describes your family right now. If a statement almost describes your family, but not quite, select the number just below the statement. For example, if the statement under 3 almost describes your family, but not quite, select the 2.
You will notice that the responses include the word “we.” This refers to your family. It’s okay if you are answering just for yourself (your own opinion or experience) or as a family with a shared opinion or experiences
If your child sees more than one service provider, you may fill out a survey for each provider.

COUNTY IN WHICH CLIENT RESIDES:
PROVIDER OF SERVICES TO CLIENT:
CLIENT RACE:	American Indian or Alaska Native Asian African American Pacific Islander White
CLIENT ETHNICITY:	Hispanic Non-Hispanic
PARENT'S PASSWORD:

NOTE: Please fill in your county of residence. If you have complaints, please call 501-682-8703.