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:	ARKANSAS ASHLEY BAXTER BENTON BOONE BRADLEY CALHOUN CARROLL CHICOT CLARK CLAY CLEBURNE CLEVELAND COLUMBIA CONWAY CRAIGHEAD CRAWFORD CRITTENDEN CROSS DALLAS DESHA DREW FAULKNER FRANKLIN FULTON GARLAND GRANT GREENE HEMPSTEAD HOT SPRING HOWARD INDEPENDENCE IZARD JACKSON JEFFERSON JOHNSON LAFAYETTE LAWRENCE LEE LINCOLN LITTLE RIVER LOGAN LONOKE MADISON MARION MILLER MISSISSIPPI MONROE MONTGOMERY NEVADA NEWTON OUACHITA PERRY PHILLIPS PIKE POINSETT POLK POPE PRAIRIE PULASKI RANDOLPH SALINE SCOTT SEARCY SEBASTIAN SEVIER SHARP SAINT FRANCIS STONE UNION VAN BUREN WASHINGTON WHITE WOODRUFF YELL OUT OF STATE Lousianna Missouri Mississippi Oklahoma Tennessee Texas All other states
PROVIDER OF SERVICES TO CLIENT:	ABC Happy Kids Therapy Services Absolute Pediatric Therapy Achieve Center for Therapy, PLLC Advance, Orsolya Toth Advantages of Southeast Arkansas Allied Therapy & Consulting Services, P.A. Archild, Inc. Arkansas Child Care Service, Inc. Arkansas Department of Human Services Arkansas Enterprises for the Developmentally Disabled, Inc. Arkansas Quality Therapy Co. Arkansas Regional Therapy Services, LLC Arkansas School for the Deaf Outreach Support Services Arkansas Therapy Outreach, LLC Barbara Cates Blooming Tree Therapy LLC Boone County Special Services Bost, Inc Brixey Therapy Services Building Bridges Developmental and Community Services, Inc. C & D Disability, Inc CB King Memorial School Inc. Chatterbug Therapies, Inc Child's Play, Inc. Childcare Resources and Consulting, Inc. Children's Therapy Services Children's Therapy Team Chuck's Developmental Outreach Civitan Services Communication Made Easy Inc. Community School of Cleburne County, Inc. Conway County Center for Exceptional Children, Inc. Craine Therapy, Ltd Creative Learning Therapy, Inc. Cross Therapy Services, LTD Crossroad House for Kids Crystal Evans D'Ann Diles Developmental Resources Management, Inc. Diversified Developmental Services, Inc. DJ Early Learning Developmental Center Drew's Early Learning Inc. Eagle Family Therapy Services, Inc. Early Connections, LLC Easter Seals Arkansas Elizabeth Richardson Center Eva Sykes First Step, Inc. Focus Inc Focus, Inc. Forrester-Davis Development Center, Inc. Francis A. Allen School, The (The Allen School) Frank C. Steudlein Learning Center Frankie's Child Care & Learning Center Franklin County Learning Center, Inc. Friendship Community Care From The Beginning Great Beginnings Child & Enrichment Center, Inc Great Expectations Developmental Center Hands On Learning Hands That Help Hands-On Therapy, Inc. Happyland Childcare Center Inc. Harris Pediatric Therapy Helping Hand Learning Center Heltco Hours of Joy Childcare Inc. Howard County Children's Center, Inc. HRS Associates Imagination Station & On-Track Therapy In-Sync Pediatric Therapy Center, Inc. Integrity, Inc. Jenkins Memorial Center Julie Foster Jumping Jelly Beans Pediatric Therapy Kid Quest Kids EI Melbourne dba Kidspiration Outpatient Services Too Kids Spot, LLC KidsChoice Therapeutic Services, Inc. Kidsource Therapy Kidspiration Outpatient Therapy Services, Inc. DBA Kids EI Mountain Home Kidz R First KidzKan Lawrence County Cooperative School, Inc. Learning Center of North Arkansas, The Little Angels Therapy Little Bitty City Therapeutic Services Logan County Day Service Center for Limited Children Lynn M Center, Inc (dba) Northwest Pediatric Therapy Margaret A. Shatford Marilyn Burks Milestones Services Miss Polly's Day Care Center Monroe County Human Development Center Neighborhood Cope Network of Community Options, Inc. North Hills Services, Inc., Children's Developmental Center Ouachita Industries, Inc./Ouachita Child Enrichment Center Outside the Box Therapy, LLC Ozarks Occupational Therapy, Inc Pathfinder Preschool Pathfinder, Inc Pathways Pediatric Therapies Pattillo Center School, Inc Pediatric Therapy, Inc. Pediatrics Plus Therapy Services Personal Therapy Group, LLC. Personal Therapy of NEA, Inc DBA Kidspot Phillips County Developmental Center Physicians Therapy Group Polk County Developmental Center, Inc Prescott/Nevada County Day Service Center Progressive Pediatrics, Inc. Pryor Physical Therapy Rainbow of Challenges, Inc. Ramey Speech Clinic, Inc Reaper Physical Therapy, Inc. Recovery Zone Pediatric Therapy Rehabilitation Network Outpatient Services, LLC Resource Access, Inc. Resources Coordination Inc. Seketa Ross Leap Ahead Sevier County Developmental Center South Arkansas Developmental Center for Children and Families Spa, Inc. Sparkman Learning Center Speech Pathology Associates, Inc. dba Sensational Kids Speech Solutions Inc. St. Francis Area Developmental Center Staiger Communication Services, LLC Stephens Speech Clinic PA Stepping Stone School for Exceptional Children, Inc. Sunshine School & Development Center Texarkana Special Education Center The Community School, Inc. The Doni Martin Center for Developmental Services The Learning Center of Northeast Arkansas, Inc. The Sunshine School, Inc. Thera Play, Inc Thera-Play Pediatrics TheraKids, LLC Therapy 4 Kids Therapy Providers Therapy Tree TheraTeam Rehab Services United Cerebral Palsy Van Buren County Special School Watson Speech and Hearing Specialists Wendy Cassady Speech Pathology, Inc Yell County Special Services Center, Inc York W. Williams, Jr. Child Development Center, Inc
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.