* 1. My child's diagnosis is

* 3. Do you pay a premium (or have $ deducted from your pay) for your child to be on your private health insurance?

* 5. Does your child receive services from Birth to 3 Early Intervention?

* 6. Does your child receive special education services under an IEP?

* 7. If yes, did the School District ask you

  yes no
To enroll your child in Medicaid?
For your permission to bill Medicaid?

* 8. Does your child receive services through any of these waivers?

  yes no
Early Intervention

* 9. Please tell us a little about your family

Counting the child you told us about, siblings and the parents who live with the child, how many people are in your family?

* 10. What is the family's annual income?

* Does your income change from month to month?

* Is there anything else you'd like to tell us? (For instance, that you have substantial out of pocket costs that are not reflected in the available answers, that you rely on family members to provide care, etc.)