Intensive Therapy Program Survey
INTENSIVE SESSION START DATE
-
Month
-
Day
Year
Date
Clinic Location
*
Los Angeles
Boston
Denver
Austin
Chicago
Sydney
Melbourne
Brisbane
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
Back
Next
Please rate your child's (or your) therapy team as a whole below.
★
★★
★★★
★★★★
★★★★★
QUALITY OF THERAPY
COMMUNICATION AMONGST TEAM
COMMUNICATION WITH PARENT
COMMUNICATION OF THERAPY GOALS
COMMUNICATION OF HOME PROGRAM
Please rate the Front Desk Team as a Whole
★
★★
★★★
★★★★
★★★★★
FRIENDLINESS
HELPFULNESS
RESPONSIVENESS
COMMUNICATION OF PROCEDURES
Specific Feedback about Front Desk Staff Member:
Back
Next
The next sections pertain to each of your child's (or your) therapists individually. Please write each therapist's name below and provide feedback if you have any so we can continue to improve our service.
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
Back
Next
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
Back
Next
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
Back
Next
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
Back
Next
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 (or yourself)?
Do you have any tips for families (or patients) attending their first session?
Additional Comments or Suggestions:
Would you like us to contact you for ongoing sessions following your intensive?
*
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, i'm already receiving ongoing services with NAPA!
No thanks
Great! What is your availability for scheduling?
Which services would you like to schedule?
Physical Therapy/Physiotherapy
Occupational Therapy
Speech Therapy
Feeding Therapy
DMI - Dynamic Movement Intervention
Other
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
Should be Empty: