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Patient Feedback
 

Patient Feedback | Ascent Children's Health Services

Patient Survey

Please complete the following survey regarding patient satisfaction. If a particular question or service does not apply to you or your child select "N/A", otherwise select the number of the response that most closely reflects how you feel about the question. Also comment on any positive or negative experiences you might have had in any area. The form will automatically be e-mailed to Ascent when you are finished and hit the submit button at the bottom.

GENERAL QUESTIONS (Fill in the blank)

1. Child's name (Optional):
2. Referred By (name of PCP):
3. Why was your child referred to our program?
4. Date:

SATISFACTION / EFFICIENCY (Select a number)


 Very
Poor 		Poor Fair Good Very
Good 		N/A
1. Facilities (cleanliness, equipment, space etc.)
 1 2 3 4 5 NA
2. Staff was helpful and courteous 1 2 3 4 5 NA
3. Staff was sensitive to your child's cultural/ethnic background and needs 1 2 3 4 5 NA
4. Length of time it took to enroll your child 1 2 3 4 5 NA
5. The staff's focus on recovery for your child 1 2 3 4 5 NA
6. You were given hope that your child would progress 1 2 3 4 5 NA
7. You and your child were treated with dignity and respect 1 2 3 4 5 NA
8. You were given an opportunity to make informed choices regarding your child's treatment 1 2 3 4 5 NA
9. Satisfaction with the number of staff per child 1 2 3 4 5 NA
10.Your concerns/grievances were taken seriously 1 2 3 4 5 NA
11. Your concerns/grievances were responded to in a timely manner 1 2 3 4 5 NA
12. Overall satisfaction with your child's care with us 1 2 3 4 5 NA
Comments (describe good or bad experiences):

EFFECTIVENESS

How effective do you feel our program has been in: Very
Poor 		Poor Fair Good Very
Good 		N/A
1.Improving your child's health and development 1 2 3 4 5 NA
2.Improving your child's behavior (if applicable) 1 2 3 4 5 NA
3.Improving your child's level of functioning with family 1 2 3 4 5 NA
4.Improving your child's level of functioning with peers 1 2 3 4 5 NA
5.Improving your child's self esteem 1 2 3 4 5 NA
6.Helping your child to improve overall 1 2 3 4 5 NA
7.How has your child's initial problem/issue changed since beginning services with us? 1 2 3 4 5 NA
8.How has your child's behavior changed since beginning services with us? 1 2 3 4 5 NA
9.How has your child's health changed since beginning services with us? 1 2 3 4 5 NA
Comments/Suggestions (describe good or bad experiences):
How could we be more helpful to you and your child?

ACCESS


Very
Poor 		Poor Fair Good Very
Good 		N/A
1.Convienience of clinic's location 1 2 3 4 5 NA
2.Ease with which you could enter and move around our building 1 2 3 4 5 NA
3.Hours of care available (clinic's open hours) 1 2 3 4 5 NA
4.Availability of the Director 1 2 3 4 5 NA
5.Availability of your child's Developmental Specialist 1 2 3 4 5 NA
5.Availability of clinic case Manager 1 2 3 4 5 NA
6.Availability of other staff for assistance if needed 1 2 3 4 5 NA
7.Response to your phone calls (timely, courteous) 1 2 3 4 5 NA
8.Being provided with copies of evaluations completed on your child 1 2 3 4 5 NA
9.Evaluations results were explained in a way that I could understand 1 2 3 4 5 NA
10.Feeling welcome to visit the clinic at any time 1 2 3 4 5 NA
11.Availability of educational information to better help you understand your child's diagnosis/treatment 1 2 3 4 5 NA
12.Length of time between your doctor referring you to our program and actually beginning services 1 2 3 4 5 NA
13.Our explanation of your options for transportation 1 2 3 4 5 NA
14.How quickly you were provided transportation (if needed) 1 2 3 4 5 NA
Comments/Suggestions (describe good or bad experiences):


 

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