D2 Participant Session Feedback Form

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Who is completing this Feedback?* This field is required.

The participant

Participant with support

Family member (Mum, Dad, Brother, Sister, Relation)

Doctor, Allied health professional, Case manager

Support worker, Other

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Information about this Feedback

Completing this feedback is one way people can tell us how the sessions are going and what to focus on to make the sessions better.

The information provided in this form is private and confidential and will not be shared with anyone without concent, the information is collected and used to record and measure progress in a subjective way. You will receive a copy of this feedback once submitted; you may want to keep it for your records.

This form should only be completed by participants of Immersion Therapy and people who support them.

If you have a complement or complaint about Determined2 please click here https://determined2.com.au/compliments_or_complaints/

You can also give feedback to the NDIS Commission:

They take feedback or complaints about services that you are not happy with. You can call them on: 1800 035 544

Or you can call the National Relay Service and ask for 1800 035 544. You can also do this online here: https://www.ndiscommission.gov.au/participants/complaints You can also call the NDIA on 1800 800 110.

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Your Name* This field is required.

First Name

Last Name

4

Participants Name* This field is required.

First Name

Last Name

5

Your Email Address* This field is required.When completed we will send you a copy

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Tell us how the Immersion Therapy sessions are working.

Each question has a scale or slide bar below it ranging from 0 to 10. Slide it to the right for a positive response, or to the left for a negative one. Leave it in the middle if you don’t know or feel the question doesn’t relate to you.

Choose 0 1 2 3 4 if you have had a negative experience
Leave it at 5 if you don’t feel the question relates to you or are unable to say
Choose 6 7 8 9 10 if you have had a positive experience

This information will assist us in tailoring our service to an individual, it will also assist us in preparing and reporting any progress.

You can always tell us more in the optional comments.

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How would you rate your most recent Immersion Therapy session?0-4 Negative Experience (5-Neutral or Unable to Say) 6-10 Positive Experience

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How would you rate the participant's most recent Immersion Therapy session?0-4 Negative Experience (5-Neutral or Unable to Say) 6-10 Positive Experience

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Have you experienced Improved Mobility* This field is required.0-4 Negative Experience (5-Neutral or Unable to Say) 6-10 Positive Experience

10

Has the participant experienced Improved Mobility* This field is required.0-4 Negative Experience (5-Neutral or Unable to Say) 6-10 Positive Experience

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Have you experienced Muscle Strengthening and Conditioning* This field is required.0-4 Negative Experience (5-Neutral or Unable to Say) 6-10 Positive Experience

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Has the participant experienced Muscle Strengthening and Conditioning* This field is required.0-4 Negative Experience (5-Neutral or Unable to Say) 6-10 Positive Experience

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Have you experienced Increased Confidence and Self-Esteem* This field is required.0-4 Negative Experience (5-Neutral or Unable to Say) 6-10 Positive Experience

14

Has the participant experienced Increased Confidence and Self-Esteem* This field is required.0-4 Negative Experience (5-Neutral or Unable to Say) 6-10 Positive Experience

15

Have you experienced Improved Health and Wellbeing* This field is required.0-4 Negative Experience (5-Neutral or Unable to Say) 6-10 Positive Experience

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Has the participant experienced Improved Health and Wellbeing* This field is required.0-4 Negative Experience (5-Neutral or Unable to Say) 6-10 Positive Experience

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Have you experienced Increased Community Participation* This field is required.0-4 Negative Experience (5 Neutral or Unable to Say) 6-10 Positive Experience

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Has the participant experienced Increased Community Participation* This field is required.0-4 Negative Experience (5 Neutral or Unable to Say) 6-10 Positive Experience

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Have you experienced Improved Relationships and Social Skills* This field is required.0-4 Negative Experience (5-Neutral or Unable to Say) 6-10 Positive Experience

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Has the participant experienced Improved Relationships and Social Skills* This field is required.0-4 Negative Experience (5-Neutral or Unable to Say) 6-10 Positive Experience

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Optional Comments, what other kind of benefits have you noticed?Please describe or click "Next" if you don't wish to say..

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Optional Comments, are there any negative effects as a result of involvement in Immersion Therapy?Please describe or click "Next" if you don't wish to say..

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Has Immersion Therapy improved your day to day life?* This field is required.0-4 Negative Experience (5-Neutral or Unable to Say) 6-10 Positive Experience

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Has Immersion Therapy improved the participant day to day life?* This field is required.0-4 Negative Experience (5-Neutral or Unable to Say) 6-10 Positive Experience

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Optional Comments, describe day to day life improvementsPlease describe or click "Next" if you don't wish to say..

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How would you rate the level of care taken by staff to ensure safety?0-4 Negative Experience (5-Neutral or Unable to Say) 6-10 Positive Experience

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Do you have suggestions to work on goals?If yes, please describe or click "Next" if you don't wish to say..

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Is there anything you don't enjoy about Immersion Therapy? If yes, please describe or click "Next" if you don't wish to say..

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Is there anything the participant doesn't enjoy about Immersion Therapy? If yes, please describe or click "Next" if you don't wish to say..

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Do you have any recommendations or comments about our service?If yes, please describe or click "Next" if you don't wish to say..

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Privacy and Information

Determined2 is committed to protecting your privacy. We collect and handle personal information that you provide to develop your personal plan.

You also have the right to access your information and seek its correction under the Freedom of Information Act 1982. For information about making a Freedom of Information (FOI) application, please contact the Office of the Australian Information Commissioner on 1300 363 992.

Determined2 will only use your information in accordance with relevant privacy and other laws. For us to provide the best possible service, we may need to share your personal information with others, we will seek your consent to do so where required.

If you wish to contact Determined2 about the information that you provide on this form, please call 0417 932 466 or email admin@determined2.com.au

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Who would you like to receive this information?You can choose one, multiple or none, they will receive a copy once submitted.

Doctor, Allied Health Professional

Other Person, Friend

Family Member

Assistant or Support Worker

Case Manager

No one else (select submit below)

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Doctor (Health professional) Name and Clinic where you see them* This field is required.

Name first, then Clinic Name

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Doctor (Health professional) Email* This field is required.

example@example.com

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Family member's Name* This field is required.

First Name

Last Name

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Family Member Email* This field is required.

example@example.com

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Other Person or Friend's Name* This field is required.

First Name

Last Name

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Other person or Friend's Email* This field is required.

example@example.com

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Assistant or Support worker's Name* This field is required.

First Name

Last Name

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Assistant or Support worker's Email* This field is required.

example@example.com

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Case Manager's Name* This field is required.

First Name

Last Name

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Case Manager's Email* This field is required.

example@example.com