1. Background Information

* 1. What is the age of your CHILD?

* 2. What is the gender of your CHILD?

* 3. What is your child's diagnosis(es)? Check ALL that apply.

* 4. Has your CHILD had previous hospital stays? If yes, what hospital(s) did your child stay at?

* 5. Has your CHILD had previous surgeries? If yes, what hospital(s) did your child have a prior surgery?

* 6. Does your child currently attend outpatient therapies/services?

* 7. Prior to this hospital stay, how recent has your child attended outpatient therapies/services?

  Within past 2 months Within past 6 months Within past 12 months
OT
PT
Speech
Psychology
Therapeutic Recreation
School (therapies)

T