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Easter Seals Discharge Survey
1.

Please enter today's date:
 

50 characters left.
2.

Please tell us about you and your family.

First Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

3.

I received the following services from Easter Seals: (Please feel free to add the name of your service provider(s)
Occupational Therapy
Physical Therapy
Speech Therapy
Feeding Therapy
Developmental Therapy
Aquatic Therapy
Counseling
Autism Diagnostic Clinic
Applied Behavior Analysis
The P.L.A.Y. Project
Assistive Technology Clinic
Orthotics Clinic
Rehabilitation Coordination
Other
  • Comment:

  • 500 characters left.
4.

My child received services at:
Peoria Facility
Bloomington Facility
Other
  • Comment:

  • 500 characters left.
5.

Staff were friendly, professional, helpful and prompt.
 Very Dissatisfied Somewhat Dissatisfied Satisfied Very Satisfied Extremely Satisfied N/A 
Therapists
Coordinators
Receptionists
Client Financial Services
  • Comment:

  • 500 characters left.
6.

Staff listened to our concerns and answered our questions.
 Very Dissatisfied Somewhat Dissatisfied Satisfied Very Satisfied Extremely Satisfied N/A 
Therapists
Coordinators
Receptionists
Client Financial Services
  • Comment:

  • 500 characters left.
7.

Realistic goals were discussed and set.
 Very Dissatisfied Somewhat Dissatisfied Satisfied Very Satisfied Extremely Satisfied 
Thearpists
Coordinators
8.

The frequency and length of sessions met our expectations.
 Very Dissatisfied Somewhat Dissatisfied Satisfied Very Satisfied Extremely Satisfied N/A 
Therapy
Specialty Clinic
  • Comment:

  • 500 characters left.
9.

Services were provided in a timely manner.
 Very Dissatisfied Somewhat Dissatisfied Satisfied Very Satisfied Extremely Satisfied 
Thearpy
Specialty Clinic
  • Comment:

  • 500 characters left.
10.

Services were beneficial and expectations were met.
 Very Dissatisfied Somewhat Dissatisfied Satisfied Very Satisfied Extremely Satisfied N/A 
Therapy
Specialty Clinic
  • Comment:

  • 500 characters left.
11.

Staff gave us a good understanding of our child's needs, abilities and potential.
 Very Dissatisfied Somewhat Dissatisfied Satisfied Very Satisfied Extremely Satisfied N/A 
Therapist(s)
Physician(s)
  • Comment:

  • 500 characters left.
12.

The environment and facilities were safe, attractice and accessible.
 Very Dissatisfied Somewhat Dissatisfied Satisfied Very Satisfied Extremely Satisfied N/A 
Peoria Facility
Bloomington Facility
  • Comment:

  • 500 characters left.
13.

As a result of services, my family and I experienced (choose all that apply):
Reduced stress
Improved parent/child interaction
A better understanding of my child
Improved quality of liffe
  • Comment:

  • 500 characters left.
14.

Based on your experience, I would feel comfortable referring other families to the program.
Not at all
Yes
Definitely
  • Comment:

  • 500 characters left.

Please help us improve our services to your family and others by answering the following questions.
 
15.

Were there any other services you may have needed that were not available?
 

350 characters left.
16.

Are there any other ways in which we can help you?
 

350 characters left.
17.

What services is your child currently receiving?
Early Childhood Education Program at School
Private Pre-School
Therapy in the School
General School Services
Therapy with another Provider
Community Recreation Program
None
Other
  • Comment:

  • 500 characters left.
18.

Are there additional resources we can help you with?
Behavioral Therapy
Disability Specific Education
Therapeutic Resources
Equipment
Advocacy
Parent Support Group
Client Centered Support Group
Other
  • Comment:

  • 500 characters left.
19.

Please add any additional comments regarding your experience with Easter Seals.
 

350 characters left.