www.royalrehab.com.au
1. Spinal Injury Unit - Client Feedback Survey
25%
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 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 Royal Rehabilitation Centre (Royal Rehab):
Health condition that lead to contact with Royal Rehabilitation Centre (Royal Rehab):
Brain Injury
Spinal Injury
Stroke
Orthopaedic condition
Other, please specify:
7
. Services Used (Tick all that apply)
If you have recently used more than one service, please only fill out this survey in relation to the Spinal Injury Unit. 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.
Services Used (Tick all that apply) If you have recently used more than one service, please only fill out this survey in relation to the Spinal Injury Unit. 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.
Spinal Injury Unit (Moorong)
Brain Injury Unit
Brain Injury Community Rehabilitation Team (BICRT)
Adult Rehabilitation Services (CARS/Coorabel Unit)
Aged Rehabilitation Services (Dixson Unit)
Outpatients Department
Driving Assessment Centre
Community Accommodation and Support Service (Group Homes)
Extended Care Service / Weemala
Neurobehavioural Rehabilitation Service
Home Based Rehabilitation Service
Other (please specify)
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