* 1. My child's primary care provider(PCP) has asked me to share with him/her my knowledge and expertise as the parent or caregiver of a child with special healthcare needs.

* 2. My child's PCP has asked me how my child's condition affects our entire family.

* 3. My child's PCP understands how my child's medical, behavioral, or other conditions affect his/her day-to-day life.

* 4. The office staff/nursing staff understands how my child's medical behavioral, or other conditions affect his/her experience in the office.

* 5. My PCP and/or care coordinator:

  Yes No
a. Help develop a healthcare plan for my child.
b. Use a care plan to help follow my child's progress.
c. Review and update the care plan with me regularly.

* 6. In the last 12 months, how much of a problem was it to get rehabilitation/therapeutic services or medical equipment for your child?

* 7. What does your child need that you are not currently receiving?

* 8. Are you interested in participating in a parent support group relevant to your child's medical/behavioral/emotional condition?

* 9. Please add any further comments below that would be valuable feedback for improving your child's care and experience in our office.

* 10. (Optional) Please provide your child's name in the box below.

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