EI Telehealth Family Survey

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

The Department of Public Health (DPH) and the Early Intervention Parent Leadership Project (EIPLP) would like to hear about your experience with receiving EI services during the COVID-19 pandemic. Below are 10 questions that ask you about telehealth services, also sometimes called tele-intervention. It should take less than 10 minutes to complete and all questions are optional. Please only complete one survey per family. If you do not have access to the Internet, please contact the EIPLP at (617) 645-1763 from 12pm - 8pm on Mondays and Wednesdays, to complete the survey in person or if you need an interpreter.

This survey is also available in the following languages at www.eiplp.org/coronavirus-covid-19/:
Arabic
Haitian-Creole
Portuguese
Spanish
Vietnamese

How old is your child?

0 - 12 months

13 - 24 months

25 - 36 months

Clear selection

How long have you received EI services?

0 - 12 months

13 - 24 months

25 - 36 months

Clear selection

How would you describe yourself? (please check all that apply)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Prefer not to answer

Telehealth services were explained to me by my EI service provider.

When did your EI program ask you if you would like to have EI telehealth services?

My program has not offered EI telehealth services (please skip the next question)

Week of March 23

Week of March 30

Week of April 6

Week of April 13

I don't remember.

My EI service provider offered telehealth services via: (please check all that apply)

Phone (cell or landline)

Video conferencing (Zoom, Google Hangout, Skype, etc.)

Are you choosing to have some or all of your services provided as a telehealth service?

If you decided not to have visits by telehealth, could you tell us why? (please check all that apply)

Limited/no access to a device

Limited data/no access to Internet or Wi-Fi

Language barrier

My family's schedule/availability

Staff schedule/availability

I'm not interested in telehealth visits

My family's comfort using technology

We tried it, but did not like it

Other:

What services have you received by telehealth? (please check all that apply)

Home visits

Intake visit

Evaluations/assessments

IFSP Meetings

IFSP Review Meetings

Transition Planning Conferences

Child groups (EI only and community)

Parent groups

On a scale of 1 (very satisfied) to 5 (not satisfied), how satisfied are you with your telehealth services and why?

Thank you for sharing your experience with us. Your input is vital to helping to make EI services and supports in Massachusetts better!

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms