• 
• Intensive Therapy Program Survey
• INTENSIVE SESSION START DATE
   -Month -DayYear

  Date
• Clinic Location*
  Los Angeles Boston Denver Austin Chicago Sydney Melbourne Brisbane London Pop-Up
• Please rate your overall NAPA experience
  1 2 3 4 5
• 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

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  Next

• Please rate your child's (or your) therapy team as a whole below.

  	★	★★	★★★	★★★★	★★★★★
  QUALITY OF THERAPY
  COMMUNICATION AMONGST TEAM
  COMMUNICATION WITH PARENT
  COMMUNICATION OF THERAPY GOALS
  COMMUNICATION OF HOME PROGRAM

• Please rate the Front Desk Team as a Whole

  	★	★★	★★★	★★★★	★★★★★
  FRIENDLINESS
  HELPFULNESS
  RESPONSIVENESS
  COMMUNICATION OF PROCEDURES

• Specific Feedback about Front Desk Staff Members:
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• The next sections pertain to each of your child's (or your) therapists individually. Please write each therapist's name below and provide feedback if you have any so we can continue to improve our service.

   
• Therapist Name:

• 	★	★★	★★★	★★★★	★★★★★
  QUALITY OF THERAPY
  PROFESSIONALISM
  RAPPORT WITH CHILD
  USE OF TIME
  COMMUNICATION WITH PARENT
  PARENT EDUCATION

• WOULD YOU LIKE THIS THERAPIST TO BE A PART OF YOUR TREATMENT TEAM IN THE FUTURE?
  YESNO
• ADDITIONAL FEEDBACK ABOUT THIS THERAPIST
• Back

  Next

• Therapist Name:

• 	★	★★	★★★	★★★★	★★★★★
  QUALITY OF THERAPY
  PROFESSIONALISM
  RAPPORT WITH CHILD
  USE OF TIME
  COMMUNICATION WITH PARENT
  PARENT EDUCATION

• WOULD YOU LIKE THIS THERAPIST TO BE A PART OF YOUR TREATMENT TEAM IN THE FUTURE?
  YESNO
• ADDITIONAL FEEDBACK ABOUT THIS THERAPIST
• Back

  Next

• Therapist Name:

• 	★	★★	★★★	★★★★	★★★★★
  QUALITY OF THERAPY
  PROFESSIONALISM
  RAPPORT WITH CHILD
  USE OF TIME
  COMMUNICATION WITH PARENT
  PARENT EDUCATION

• WOULD YOU LIKE THIS THERAPIST TO BE A PART OF YOUR TREATMENT TEAM IN THE FUTURE?
  YESNO
• ADDITIONAL FEEDBACK ABOUT THIS THERAPIST
• Back

  Next

• Therapist Name:

• 	★	★★	★★★	★★★★	★★★★★
  QUALITY OF THERAPY
  PROFESSIONALISM
  RAPPORT WITH CHILD
  USE OF TIME
  COMMUNICATION WITH PARENT
  PARENT EDUCATION

• WOULD YOU LIKE THIS THERAPIST TO BE A PART OF YOUR TREATMENT TEAM IN THE FUTURE?
  YESNO
• ADDITIONAL FEEDBACK ABOUT THIS THERAPIST
• Back

  Next

• Do you plan to return to NAPA?
  Yes No Maybe
• Please let us know how we can improve our service.
• Did you love your experience? Let us know why!
• What improvements have you noticed in your child (or yourself)?
• Do you have any tips for families (or patients) attending their first session?
• Additional Comments or Suggestions:
• Would you like us to contact you for ongoing sessions following your intensive?*
  Yes, I am interested in weekly sessions in clinicYes, I am interested in weekly telehealth sessionsYes, I am interested in periodic telehealth sessionsNo thanks, i'm already receiving ongoing services with NAPA!No thanks
• Great! Please provide your availability for scheduling below.

  	Morning	Afternoon
  Monday
  Tuesday
  Wednesday
  Thursday
  Friday
• Great! What is your availability for scheduling?
• Which services would you like to schedule?
  Physical Therapy/PhysiotherapyOccupational TherapySpeech TherapyFeeding TherapyDMI - Dynamic Movement InterventionOther 
  
• Patient Name - This will only be shared with our scheduling department to reach out with our availability.*
  First NameLast Name
• We love receiving your feedback and sharing it with other NAPA families! If you are happy for us to share, please include your name below.
  First NameLast Name
• Email
  example@example.com
• Submit
• Should be Empty: