Early Intervention: Parent Questionnaire Answers marked with a * are required.
	1. Early Intervention Parent Questionnaire: Page One
	1*. Please provide the following information. Name City Province Email Address Phone Number
	2. What is your child's diagnosis?
	3. What is the name of the organization(s) through which your child receives Early Intervention services?
	4. How old is your child?
	5. How old was your child when he/she received his/her diagnosis?
	6. How old was your child when he/she began receiving early intervention services?
	7. On average, how many weekly hours of early intervention services does your child receive?
	8. Does your child receive early intervention services from one service provider or from multiple sources? One Service Provider Multiple Service Providers
	9. How long has your child been receiving services from his or her current service provider(s)?