Survey Form

Child's Name*

Parent / Guardian Name: *

Parent / Guardian Email: *

What State do you live in?

DC

Delaware

Pennsylvania

Virginia

What type of services do you receive? Choose all that apply.*

OT

PT

SI

Speech

Does your sunrise therapist(s) provide opportunities for you and other family members to be involved in therapy? *

YES

NO

SOMETIMES

Has your therapist(s) provided you with guidance to continue a home program of therapeutic activities? *

YES

NO

SOMETIMES

Would you recommend Sunrise Therapy to others in need of early intervention services?*

YES

NO

SOMETIMES

Your feedback is important