New Patient Feedback Form
We like to collect feedback from new clients. Please complete the following questions and provide any additional information you would like to share. Your responses are anonymous unless you choose to provide your child's name.
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Email *
1. The scheduling process met my family's needs *
Additional comments regarding scheduling
2. I felt welcomed upon entering the clinic for the first time *
Additional comments
3. The office assistant cooperatively schedules, cancels, and re-schedules appointments *
Additional Comments
4. Communication from staff is completed in a timely fashion (calls, emails, etc) *
5. What is the name of your child's therapist? *
6. My child’s therapist accurately and thoroughly evaluates my child’s needs. *
7. My child’s therapist provides a clear explanation of my child’s evaluation results and treatment plan. *
8. My child’s therapist collaborates with me and my child in order to establish appropriate treatment goals. *
9. My child’s therapist provides a clear explanation of treatment activities, either during the treatment session or following the session. *
10. My child’s therapist uses activities that motivate my child and is able to effectively support his or her participation in each session. *
11. My child’s therapist frequently provides useful tips, strategies, education, or home program activities to help my child progress. *
12. My child’s therapist actively works to establish a strong relationship with my child. *
13. My child’s therapist actively seeks to collaborate with all members of my child’s team (teachers, psychologists, other family members, etc) *
14. My child’s therapist address my questions or concerns, and responds to my attempts at communication within a reasonable amount of time (emails, phone, etc) *
Please provide any additional feedback.
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