Schwartz Center for Children Consumer Satisfaction Survey: Regional Consultancy Services
	We appreciate your help as we work with you to provide the best for your child. We want to hear from you because your child is important to us. Your input about our services, both to you and your child, is necessary to improve what we do. Thank you for completing this online survey. The information you provide will only be used by the Schwartz Center. For more information, please visit our website at www.schwartzcenter.org.
	1*. Please provide child's name, address and date of birth: Child's name Address Date of birth
	2. Please provide the following information: Date of Admission Person Completing Survey Relationship Phone number Email address
	3. Please list the services that you received from the Regional Consultation Program. Check all that apply. Respite Consultation Training Equipment Specialty Clinic: Genetics Specialty Clinic: Pedi-Rehab/Mobility -- Dr Webster -- Bracing and Orthodics -- Adaptive Equipment
	4. Was this program helpful to you and your family? Yes No
	5. Did the program respond to your needs? Yes No
	6. Add additional comments here regarding the above questions
	7. Do you have concerns with your child that we can assist in addressing?
	8. Do you have any questions, comments, or concerns?
	9. Can the Regional Consultation Program help you with: child specific consultation your child's 3.0 transition training your respite provider support groups equipment loan Pedi-Rehab specialty clinic consult to your day care provider attending workshops/training opportunitities finding a respite provider sibling support group genetics group
	Powered by ZapSurvey