www.royalrehab.com.au
1. Home Based Rehabilitation Service - Client Survey
1
. Client Survey Code (Internal Use Only)
Client Survey Code (Internal Use Only)
2
. Are you utilising this service under the Transpac program?
Are you utilising this service under the Transpac program?
Yes
No
Unsure
3
. Date
DD
MM
YYYY
Please enter date in format shown.
Date Please enter date in format shown. Day
/
Month
/
Year
4
. Person completing survey:
Person completing survey:
Self/Client
Self with assistance
Family member or significant other
Carer
Other, please specify:
5
. Client gender
Client gender
Male
Female
6
. Client age group
Client age group
15-29
30-49
50-69
70-89
90+
7
. 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:
8
. Service/s used (please tick all that apply):
If you have recently used more than one service, please only fill out this survey in relation to the Home Based Rehabilitation Service. 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 and the appropriate survey will be forwarded to you.
Service/s used (please tick all that apply): If you have recently used more than one service, please only fill out this survey in relation to the Home Based Rehabilitation Service. 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 and the appropriate survey will be forwarded to you.
Home Based Rehabilitation Service
Spinal Injury Unit (Moorong)
Brain Injury Unit
Brain Injury Community Rehabilitation Team (BICRT)
Adult Rehabilitation Services (Coorabel/CARS Unit)
Aged Care Rehabilitation Service (Dixson Unit)
Outpatients Department
Driving Assessment Centre
Extended Care Services / Weemala Service
Supported Accommodation and Support Service (Group Homes)
Neurobehavioural Rehabilitation Service
Other (please specify)
33%
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