Pediatric Therapy Feedback Form
Please provide your feedback regarding your child’s recent pediatric therapy session. Your responses will help us improve our services.
How would you rate your overall satisfaction with the therapy session?
*
1
2
3
4
5
The therapist communicated clearly and effectively.
*
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
How comfortable did your child feel during the session?
*
Very comfortable
Somewhat comfortable
Neutral
Somewhat uncomfortable
Very uncomfortable
How appropriate were the therapy activities for your child’s needs?
*
Very appropriate
Mostly appropriate
Somewhat appropriate
Not very appropriate
Not at all appropriate
Please rate the following aspects of the session:
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Rows
Excellent
Good
Fair
Poor
Therapy environment
1
2
3
4
Session organization
5
6
7
8
Therapist’s attentiveness
9
10
11
12
How well did you understand the goals of the session?
*
Completely understood
Mostly understood
Somewhat understood
Did not understand
Were you given helpful suggestions or activities to try at home?
*
Yes, very helpful
Somewhat helpful
Not helpful
No suggestions given
How likely are you to recommend our pediatric therapy services to others?
*
Not likely
1
2
3
4
Extremely likely
5
1 is Not likely, 5 is Extremely likely
What did you find most helpful about this session?
*
Do you have any suggestions for improvement?
*
Submit Feedback
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