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 Achieve Center for Therapy, PLLC Advance, Orsolya Toth Advantages of Southeast Arkansas Allied Therapy & Consulting Services, P.A. Apple Flats Speech Pathology Clinic, LLC Archild, 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 BKD Holding Company LLC dba Thera Team C0 Boone County Special Services Bost, Inc Brixey Therapy Services Brooke Horn PT, LLC Building Bridges Developmental and Community Services, Inc. C & D Disability, Inc Casa Pediatric Care LLC CB King Memorial School Inc. Center For Child Development & Family Education Chatterbug Therapies, Inc Child's Play, Inc. Childcare Resources and Consulting, Inc. Children's Learning Team Children's Therapy Services Children's Therapy Team Chuck's Developmental Outreach Civitan Services Clearly Speaking, LLC 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 Crowley's Ridge Therapies, Inc. Crystal Evans CTS, LLC D'Ann Diles Davis Early Intervention Services, LLC (Early Connections, LLC) Destination Education, LLC Developmental Resources Management, Inc. Diversified Developmental Services, Inc. DJ Early Learning Developmental Center Drew's Early Learning Inc. Dynamite Therapy, LLC Dynamite Therapy, LLC Eagle Family Therapy Services, Inc. Easter Seals Arkansas Elizabeth Richardson Center Emerge Therapy Services 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 Giddy Up Therapy, LLC 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 Jocelyn Johnson Therapies Inc. dba Bloom Child Enrichment Julie Foster Jumping Jelly Beans Pediatric Therapy Kid Quest Kids Count Therapy Services LLC Kids EI Melbourne dba Kidspiration Outpatient Services Too Kids Spot, LLC KidsChoice Therapeutic Services, Inc. Kidsource Family Services, Inc. Kidspiration Outpatient Therapy Services, Inc. DBA Kids EI Mountain Home Kidz R First KidzKan Lawrence County Cooperative School, Inc. Leap Therapy Solutions Learning Center of North Arkansas, The Lisa Prescott 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 and Stages Pediatric Therapy, LLC (Blooming Tree Therapy LLC) 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 Our Little Feats, LLC Outside the Box Therapy, LLC OverTime Therapy, Inc. dba Jump Start Pediatric Ozarks Occupational Therapy, Inc Pathfinder Preschool Pathfinder, Inc Pathways Pediatric Therapies Pattillo Center School, Inc Pediatric Therapy, Inc. Pediatrics Plus Therapy Services Pendergrass Therapy Services, Inc. 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 Reach Therapy Services Reaper Physical Therapy, Inc. Recovery Zone Pediatric Therapy Regional Therapy Services, Inc. Rehabilitation Network Outpatient Services, LLC Resource Access, Inc. Resources Coordination Inc. Seketa Ross Leap Ahead Sevier County Developmental Center Simply Kids Therapy LLC 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 Pediatric Playhouse The Sunshine School, Inc. Thera Play, Inc Thera-Play Pediatrics TheraKids, LLC Therapeutic Focus, Inc Therapy 4 Kids Therapy Providers Therapy Tree TheraTeam Rehab Services Thrive Pediatric Therapy LLC United Cerebral Palsy Van Buren County Special School Walker's Tiny Talkers 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.