Patient Feedback Form

Occupational Therapy Feedback Form

Please take a few moments to complete this form.
Today's Date*

MonthDayYear
Date
Therapist's Name (optional)

First NameLast Name
What OT services did you receive?*

Individual SessionsSmall group sessionsPhone ConsultationsEvaluationGoogle Classroom (Standard & Pro Package)Unlimited Phone & Text Access (Pro Package)Other

Overall satisfaction

	Very satisfied	Satisfied	Neutral	Unsatisfied	Very unsatisfied	N/A
Intake Process
Client Resource Webpage
Phone Consultation Process
Evaluation Process
Evaluation Reports
Therapist Interactions
Types of Therapy Activities
Therapy Setting
Communication with Therapist
My Child's Progress
Home Program / Carryover Support
Accessibility to Reports in Simple Practice

Feel free to expand on any of the areas above.
What did you love most?
How can we improve?
Gathering Testimonials:

Part of growing my business includes helping people understand the benefits of what we offer. It would really mean a lot me if you wrote a quick testimonial about our time together for me to share in my marketing or website. I'm just looking for 2-4 sentences and I've included a few prompts to choose from to get started. Thanks!
What made you sign up for our program and what goals have you achieved?
Can you talk about any tangible changes that you have seen since starting therapy?
What's been your favorite or most surprising outcome of our work together?
What would you tell a friend considering Treeline Enrichment services?
Do we have permission to use your comments above in print or digital marketing?*

Yes, you can use my comments and INCLUDE my name.Yes, you can use my comments but EXCLUDE my name.You may use my first name only.Please do not include my comments.
My Name (Optional)

First NameLast Name
Type a question
Should be Empty:

Occupational Therapy Feedback Form