Intensive Therapy Program Survey
INTENSIVE SESSION START DATE
-
Month
-
Day
Year
Date
Clinic Location
*
Los Angeles
Boston
Sydney
Austin
Please rate the following categories specific to this past session. If indifferent, please leave blank.
★
★
★
★
★
★
★
★
★
★
★
★
★
★
★
INTENSIVE REGISTRATION PROCESS
PRE-INTENSIVE COMMUNICATION
THERAPY SCHEDULE
THERAPY EQUIPMENT
CLINIC CLEANLINESS
PARENT LOUNGE
CLINIC OVERALL
RECEPTION CUSTOMER SERVICE
OVERALL EXPERIENCE
ADDITIONAL COMMENTS OR SUGGESTIONS
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Please rate your child's therapy team as a whole below.
★
★★
★★★
★★★★
★★★★★
QUALITY OF THERAPY
COMMUNICATION WITHIN TEAM
COMMUNICATION WITH PARENT
COMMUNICATION OF THERAPY GOALS
COMMUNICATION OF HOME PROGRAM
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The next sections pertain to each of your child's therapists individually. Please write each therapist's name below and provide feedback if you have any.
Therapist Name:
★
★★
★★★
★★★★
★★★★★
QUALITY OF THERAPY
PROFESSIONALISM
RAPPORT WITH CHILD
USE OF TIME
COMMUNICATION WITH PARENT
PARENT EDUCATION
WOULD YOU LIKE THIS THERAPIST TO BE A PART OF YOUR TREATMENT TEAM IN THE FUTURE?
YES
NO
ADDITIONAL FEEDBACK ABOUT THIS THERAPIST
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Therapist Name:
★
★★
★★★
★★★★
★★★★★
QUALITY OF THERAPY
PROFESSIONALISM
RAPPORT WITH CHILD
USE OF TIME
COMMUNICATION WITH PARENT
PARENT EDUCATION
WOULD YOU LIKE THIS THERAPIST TO BE A PART OF YOUR TREATMENT TEAM IN THE FUTURE?
YES
NO
ADDITIONAL FEEDBACK ABOUT THIS THERAPIST
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Therapist Name:
★
★★
★★★
★★★★
★★★★★
QUALITY OF THERAPY
PROFESSIONALISM
RAPPORT WITH CHILD
USE OF TIME
COMMUNICATION WITH PARENT
PARENT EDUCATION
WOULD YOU LIKE THIS THERAPIST TO BE A PART OF YOUR TREATMENT TEAM IN THE FUTURE?
YES
NO
ADDITIONAL FEEDBACK ABOUT THIS THERAPIST
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Therapist Name:
★
★★
★★★
★★★★
★★★★★
QUALITY OF THERAPY
PROFESSIONALISM
RAPPORT WITH CHILD
USE OF TIME
COMMUNICATION WITH PARENT
PARENT EDUCATION
WOULD YOU LIKE THIS THERAPIST TO BE A PART OF YOUR TREATMENT TEAM IN THE FUTURE?
YES
NO
ADDITIONAL FEEDBACK ABOUT THIS THERAPIST
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Did your child participate in our Trexo Program
*
Yes
No
What factors influenced your decision not to participate?
Please rate the Trexo Program below
★
★★
★★★
★★★★
★★★★★
QUALITY OF PROGRAM
USE OF TIME
COMMUNICATION WITH PARENT
PARENT EDUCATION
PROGRAM VALUE
Comments regarding Trexo:
Do you plan to return to NAPA?
Yes
No
Maybe
Please let us know how we can improve our service.
Did you love your experience? Let us know why!
What improvements have you noticed in your child?
Do you have any tips for families attending their first session?
Would you like us to contact you for ongoing sessions following your intensive?
*
No thanks, i'm already receiving ongoing services!
Yes, I am interested in weekly sessions in clinic
Yes, I am interested in weekly telehealth sessions
Yes, I am interested in periodic telehealth sessions
No thanks
Great! What is your availability for scheduling?
Which services would you like to schedule?
Physical Therapy
Occupational Therapy
Speech Therapy
Feeding Therapy
CME/Medek
DMI - Dynamic Movement Intervention
Patient Name - This will only be shared with our scheduling department to reach out with our availability.
First Name
Last Name
We love receiving your feedback and sharing it with other NAPA families! If you are happy for us to use your name when sharing, please include your name below.
First Name
Last Name
Submit
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