Early Intervention Service ProviderQuestionnaire
Answers marked with a * are required.
1.
Early Intervention Service Provider Questionnaire Page One
1*.
Please provide the following information.
Contact Name
Affiliation
Address
City
Province
Email Address
Phone Number
2.
Please provide the following optional information
Fax Number
Website Address
3.
What is the total number of children enrolled in your program?
4.
What is the age range of children enrolled in your program? (check all that apply)
0 - 2 years 11 months
3 - 5 years 11 months
6 - 9 years 11 months
10 + years
5.
Approximately how many children with a developmental delay in the following age categories are enrolled in your program? [Note: developmental delay is defined as a chronological delay in the appearance of normal developmental milestones achieved during infancy and early childhood, caused by organic, psychological, or environmental factors].
0 - 2 years 11 months
3 - 5 years 11 months
6 - 9 years 11 months
10 + years
6.
What types of services are offered through your program? (check all that apply)
ASSISTIVE TECHNOLOGY (services that assist a child with a device to aid their functional capabilities
AUDIOLOGY ( services that assist children with/at risk of a hearing related problem, provide auditory rehabilitation and determine individual amplification needs)
SERVICE PLANNING (services that help families to understand and meet their child's needs)
MEDICAL SERVICES (diagnostic and evaluative services provided by a licensed physician as part of the child’s assessment)
NURSING SERVICES (services that assess the health status of the child, including the administration of medications)
NUTRITION SERVICES (services provided by a registered nurse to help address the nutritional needs of the child, including the identification of feeding problems and skills and food habits)
OCCUPATIONAL THERAPY (services that relate to self-help skills, adaptive behavior and play, and sensorimotor development to improve functional task performance)
PHYSICAL THERAPY (services to prevent or lessen movement’s dysfunction and related functional problems to promote effective environmental adaptations)
PSYCHOLOGICAL SERVICES (services that assess and address the psychological development of a child including information on learning, mental health, and development)
SERVICE COORDINATION (services that provide families with partnerships to connect to services in the community and obtain their rights)
SOCIAL WORK/FAMILY SERVICES (services which work to assess the social and emotional strengths and needs of a child and family, provide individual or group counseling or training and link families with community resources)
SPECIAL INSTRUCTION (services that involve designing learning environments and activities to promote child development and provide families with information, support and skills)
SPEECH LANGUAGE PATHOLOGY (services that address speech and/or language development and pathology, such as problems with articulation, language or fluency)
VISION SERVICES (the evaluation and assessment of visual functioning
HEALTH SERVICES (health-related services that are required to enable the child to benefit from other early intervention services)
TRANSPORTATION AND RELATED COSTS (services that cover the cost of travel and parking necessary for the child and family to be able to obtain services)
CASE REVIEW (annual or semi-annual meetings designed to evaluate and modify the child's treatment plan)
TRANSITION SERVICES (coordination of services between the centre and school)
TOY/RESOURCE LIBRARY (a library of resources for parents and children)
INFANT DEVELOPMENT/STIMULATION (program directed at children 0-3years of age)
RESPITE SERVICES (services providing temporary relief for families of children with disabilities)
PRESCHOOL SERVICES (pre-academic skill building program for children prior to school entry)
SCHOOL SERVICES (educational services modified to fit the child's specific needs)
SERVICES FOR MEDICALLY FRAGILE CHILDREN (medically necessary services that allow for service provision to children with special medical needs)
OTHER (Please Specify)
7.
Please list the professionals who provide services through your program. (check all that apply)
PSYCHOLOGIST (A professional specializing in diagnosing and treating diseases of the brain, emotional disturbance, and behavior problems)
PSYCHIATRIST (A physician (M.D.) who specializes in the prevention, diagnosis, and treatment of mental illness)
EDUCATIONAL SPECIALIST (An individual that assists children with diverse learning needs by making educational gains by making program accommodations, assisting with the learning process and monitoring success)
LICENSED EDUCATOR ( a professional with an background in educational instruction (i.e. a teacher)
PHYSICAL THERAPIST (therapist who treats injury or dysfunction with exercises and other physical treatments of the disorder)
SPEECH LANGUAGE PATHOLOGIST (a professional that provide services to assist people with communication and swallowing difficulties)
DIETICIAN/NUTRITIONIST (a specialist in nutrition that can help patients with special needs, allergies, health problems, or diet plans)
PARAPROFESSIONAL (any professional with special training in the field that is not necessarily with a professional order)
OCCUPATIONAL THERAPIST ( a professional that helps with adaptive or sensorimotor skills and works on improving the individual functional skills of the child)
SOCIAL/FAMILY SERVICE WORKER (a professional that provides support to the child and family, often with counseling, training and home visitation)
PEDIATRICIAN/DEVELOPMENTAL PEDIATRICIAN (a physician who specializes in the care of infants and children)
BEHAVIORAL CONSULTANT (a consultant that specializes in the modification and improvement of a child's behaviour eg. poor school performance, problem behaviors)
EARLY INTERVENTION SPECIALIST (a certified professional with educational background in service provision for infants and young children in need of special assistance)
RECREATION/ART/PLAY/MUSIC THERAPIST (professional using one of those four modalities to improve the functioning of children in need of special services)
OTHER (Please Specify)