Autism Diagnosis and Services Survey
Thank you for taking the time to complete this survey. Easterseals Coalition Serving Texas is interested in learning about the process that parents undertake to receive a diagnosis of Autism for their children and understanding any difficulties that they may face in that process. Additionally, we would like to understand services that parents access for their children with Autism, and insurance policies surrounding accessing those services. Please answer the following questions as honestly as possible. Your sensitive information will not be shared, and you will not be contacted about your answers unless you provide us with consent to do so.  

If you have multiple children who were diagnosed with autism, please fill out a separate survey for each child.  
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Name of person completing survey: *
Email Address *
Phone Number *
City/Town *
Zip Code *
Race/Ethnicity *
What is the primary language spoken at home? *
I would like to be contacted about my responses to this survey: *
Preferred method of contact *
What is the gender of your child that was diagnosed with Autism? *
At what age was your child officially diagnosed with Autism? *
What year was your child diagnosed with Autism? *
Does your child have another diagnosis(es) of disability or mental health condition(s)? *
If you are comfortable, please provide the name(s) of the co-occurring diagnosis or diagnoses. If your child does not have another diagnosis or you would prefer to not disclose please mark with "Not Applicable" or "Prefer to not disclose". *
Please describe why you sought to have your child evaluated. If the options provided do not describe why you sought to have your child evaluated please select "Other" and provide a description. *
Required
When seeking a professional to perform the evaluation, please mark any issues that you encountered. Please also describe other issues you may have encountered that we did not list in the space marked “Other”.   *
Required
What type of professional evaluated your child and gave him/her an official diagnosis? *
Required
If you are comfortable, please provide the name of the specialist that gave your child an official diagnosis of Autism.
Please describe the length of time that you had to wait before your child could be evaluated for an official Autism diagnosis. For example, if you contacted a Developmental Pediatrician's office on March 1st, had to fill out paperwork and have it reviewed an approved by the office, and then scheduled an appointment for October 1st, you would list 7 months in the space below.   *
Did you have to travel outside of your city/town to see the professional that evaluated your child and gave them an official Autism diagnosis? *
Please describe the distance that you traveled (miles) and the city/town where your child was officially diagnosed with Autism: *
If known, please list the instrument that was utilized to officially diagnose your child with Autism. If the instrument utilized is not listed, please select "Other" and describe.   *
Required
Did you have to have your child evaluated multiple times before receiving an Autism diagnosis? *
If your child was evaluated multiple times before receiving an Autism diagnosis, how many times did you have to have your child evaluated before they received an official Autism diagnosis? Otherwise, mark "Not Applicable". *
If you had to have your child evaluated multiple times before receiving an official Autism diagnosis, list the type of professional who first evaluated your child and did not give an official Autism diagnosis: *
Required
If you had to have your child evaluated multiple time before receiving a diagnosis, please list the instrument that was utilized to evaluate your child the first time that they were evaluated and were not given an official Autism diagnosis. If the instrument utilized is not listed, please select "Other" and describe. *
Please select from the list below any of the following services that your child accesses due to their autism diagnosis. List other autism related therapies that your child receives in the space marked "Other".   *
Required
If you are comfortable, please provide the name of your health insurance provider (I.e. Medicaid Blue Cross Blue Shield, CHIP United Healthcare, Aetna, Humana etc.):
For each of the autism related services that you listed your child as accessing, please describe whether or not your insurance covers these services. If you access services for your child due to their autism diagnosis that are not listed below, please mark "Other" and name the therapy in your response to the next question. *
Insurance Does Cover
Insurance Does Not Cover
Not Applicable
Applied Behavioral Analysis
Equine Therapy
Music Therapy
Occupational Therapy
Physical Therapy
Play Therapy
Recreational Therapy
Speech Therapy
Theraplay
Other
For each of the services that you listed your child as accessing due to their autism diagnosis, please describe your co-pays or out-of-pocket costs, i.e. Occupational Therapy co-pay $25, Applied Behavioral Analysis $50. Please also describe the co-pays or out of pocket costs of additional services that your child accesses due to their Autism diagnosis that we did not list in the question above. *
Does your health insurance provider require an Autism diagnosis in order to access certain services (ex. Applied Behavior Analysis)?   *
If applicable, please select which services your health insurance provider requires an Autism diagnosis for. Again, please describe additional services that your child accesses due to their Autism diagnosis that we did not list in the space marked “Other”. *
Required
Does your health insurance provider require your child to be re-assessed for an official Autism diagnosis in order to continue receiving certain services? *
If your health insurance provider does require your child to be re-assessed for an official Autism diagnosis in order to continue receiving services, how often will your child have to be re-assessed?   *
Has a specialist recommended that your child access Applied Behavioral Analysis? *
If a specialist has recommended that your child access Applied Behavioral Analysis has your child been able to utilize the service? *
If a specialist has recommended that your child access Applied Behavioral Analysis and your child has not been able to access the hours recommended by the ordering specialist, please select from the following list any barriers preventing your access. Please describe any additional barriers that we did not list in the space marked “Other”. *
Required
If your child accesses Applied Behavioral Analysis and it is covered by insurance, please list the total number of hours per year that your insurance will cover.  Otherwise, please mark "Not Applicable". *
Were you aware of the Texas Health and Human Services Autism program that provides eligible children age 3-15 who have an official Autism diagnosis with focused Applied Behavioral Analysis services? *
If you have accessed the Texas Health and Human Services Commission Autism Program please describe how long you waited in order to access services. For example, if you visited the Health and Human Services Commission website and contacted a provider in your service area on March 1st, filled out an interest form, and began services on October 1st, you would list "7 months" in the space below.  If you are still currently on a waiting list, please provide the amount of time that you have been on the waiting list. Otherwise, please mark "Not Applicable." *
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