Demographics
Gender of Child Male Female
Which best describes the area you live in? Rural Suburban Urban
Marital Status Single Married Divorced or Separated Spouse Deceased
ASD History
Estimate your child's level of functioning Low Moderate High
What is your child's diagnosis? Autism Asperger Syndrome PDD-NOS Other
If other please specify
Past and Present Services
What resources have you found to be the valuable in finding information about ASD? (Mark all that apply) Medical Professionals Behavioral Professionals School System Other parents of children with ASD Web resources Support groups Other
What treatment approaches (For example behavioral, diet, medications, etc.) have you found most useful for your child? (Please Describe)
Funding of Services
What is your best estimated percent of how your child’s health care cost are covered
Public health care providers (Medicaid, State funded programs and other government funded programs.) %
Private Insurance %
Personal funds %
Other (please specify)
Do you feel that all of the necessary needs of your child with ASD are covered by your health care provider? Yes No
If no, what areas of treatment and care are lacking coverage? (ie. What additional treatments would you add if money were not an issue?)
Impact of Finances
Please describe how finances affected care and treatment your child (both in a positive and negative way).
If a family has recently had a child diagnosed with ASD, what resources and/or advice would you provide them with?