www.royalrehab.com.au
1. Driving Assessment Centre - Client Survey
1
. Client Survey Code (Internal Use Only)
Client Survey Code (Internal Use Only)
2
. Date
DD
MM
YYYY
Please enter date in format shown.
Date Please enter date in format shown. Day
/
Month
/
Year
3
. Person completing survey:
Person completing survey:
Self/Client
Self with assistance
Family member or significant other
Carer
Other, please specify:
4
. Gender
Gender
Male
Female
5
. Age Group
Age Group
15-29
30-49
50-69
70-89
90+
6
. Health condition that lead to contact with the service:
Health condition that lead to contact with the service:
Brain injury
Spinal injury
Stroke
Orthopaedic condition
Other, please specify:
7
. Service/s used (please select all that apply):
If you have recently used more than one service, please only fill out this survey in relation to the Driving Assessment Centre. For other services that you have recently used, for which you would like to provide feedback, please contact the Centre via phone: 02 9807 1144 or email: feedback@royalrehab.com.au
Service/s used (please select all that apply): If you have recently used more than one service, please only fill out this survey in relation to the Driving Assessment Centre. For other services that you have recently used, for which you would like to provide feedback, please contact the Centre via phone: 02 9807 1144 or email: feedback@royalrehab.com.au
Driving Assessment Centre
Home Based Rehabilitation Service
Spinal Injury Unit (Moorong)
Brain Injury Unit
Brain Injury Community Rehabilitation Team (BICRT)
Adult Rehabilitation Services (Coorabel/CARS)
Aged Care Rehabilitation Service (Dixson Unit)
Outpatients Department
Extended Care Services/Weemala Service
Community Accommodation and Support Service (Group Homes)
Neurobehavioural Rehabilitation Service
Other (please specify)
33%
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