Therapy Access Survey
Basic Information
1. What is the ZIP code of the individual needing therapy?
2. Please indicate the age of the person(s) in need of therapy services.
0-2
3-5
6-12
13-17
18-44
45-64
65+
3. Please list the diagnosis(es) for the individual(s) in need of services.
4. What type(s) of therapy are needed? (Select all that apply)
Physical Therapy
Occupational Therapy
Speech Therapy
Behavioral Therapy
Access to Services
5. How long did you/they wait (or have you/they been waiting) to begin therapy services?
Less than 1 month
1–3 months
3–6 months
6-11 months
12-18 months
18 months+
6. How far do you/they typically travel (or would you need to travel) for therapy services?
Less than 10 minutes
10–30 minutes
30–60 minutes
Over 1 hour
No travel needed—services are provided in my home or preferred location
7. How would you describe the availability of therapy services in your community?
Very limited / not available locally
Limited availability with long waitlists
Adequate availability
Unsure
Barriers to Care
8. What barriers have prevented you, your loved one, or your child from receiving therapy? (Select all that apply)
Long waitlists
Transportation challenges
Scheduling conflicts (work, school, etc.)
Lack of providers in my area
Insurance limitations or denials
Cost / out-of-pocket expenses
Other
9. Have you ever had to stop or reduce therapy due to these barriers?
Yes
No
If yes, please specify:
10. What type of service delivery would make it easier for your child to receive therapy? (Select all that apply)
In-home therapy
School or daycare-based services
Clinic-based services
Telehealth / virtual therapy
Flexible scheduling (evenings/weekends)
11. Is there anything else you would like to share about your experience accessing therapy services?
Thank you for your valuable feedback!
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