Intensive Therapy Program Survey
INTENSIVE SESSION START DATE
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Month
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Day
Year
Date
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Clinic Location
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Los Angeles
Boston
Sydney
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.
Therapist Name:
★
★★
★★★
★★★★
★★★★★
QUALITY OF THERAPY
PROFESSIONALISM
RAPPORT WITH CHILD
USE OF TIME
COMMUNICATION WITH PARENT
PARENT EDUCATION
WILL YOU BE REQUESTING THIS THERAPIST IN FUTURE SESSIONS?
YES
NO
ADDITIONAL COMMENTS ABOUT THIS THERAPIST
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Therapist Name:
★
★★
★★★
★★★★
★★★★★
QUALITY OF THERAPY
PROFESSIONALISM
RAPPORT WITH CHILD
USE OF TIME
COMMUNICATION WITH PARENT
PARENT EDUCATION
WILL YOU BE REQUESTING THIS THERAPIST IN FUTURE SESSIONS?
YES
NO
ADDITIONAL COMMENTS ABOUT THIS THERAPIST
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Therapist Name:
★
★★
★★★
★★★★
★★★★★
QUALITY OF THERAPY
PROFESSIONALISM
RAPPORT WITH CHILD
USE OF TIME
COMMUNICATION WITH PARENT
PARENT EDUCATION
WILL YOU BE REQUESTING THIS THERAPIST IN FUTURE SESSIONS?
YES
NO
ADDITIONAL COMMENTS ABOUT THIS THERAPIST
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Therapist Name:
★
★★
★★★
★★★★
★★★★★
QUALITY OF THERAPY
PROFESSIONALISM
RAPPORT WITH CHILD
USE OF TIME
COMMUNICATION WITH PARENT
PARENT EDUCATION
WILL YOU BE REQUESTING THIS THERAPIST IN FUTURE SESSIONS?
YES
NO
ADDITIONAL COMMENTS ABOUT THIS THERAPIST
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Did your child participate in our Trexo Program
Yes
No
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What factors influenced your decision not to participate?
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Please rate the Trexo Program below
★
★★
★★★
★★★★
★★★★★
QUALITY OF PROGRAM
USE OF TIME
COMMUNICATION WITH PARENT
PARENT EDUCATION
PROGRAM VALUE
Comments
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Do you plan to return to NAPA?
Yes
No
Maybe
Please let us know how we can improve our team or clinic prior to your child's next session.
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?
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
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