* 1. Patient Name:

* 2. Parent or Guardian of patient (if patient is under age 18):

* 3. Contact Phone Number:

* 4. Type of therapy patient was seen for:

* 5. Patient Since:

Purpose of this Survey This survey 
This survey is intended to help identify ways MECA Therapies can improve as a company, and as a way to asses how satisfied you were with the services that were provided to you or your child. Your feedback is very important to us and is crucial to our future success, so please be as honest as possible in your responses. Also know, that all gathered information is for internal purposes only and will not be disclosed or discussed with outside sources.  
Please answer the following questions to the best of your ability. If you are a parent filling out this survey please respond to the following questions as they pertain to your child and their treatment. 

* 6. Approximately how often did a MECA Therapist or Specialist see you?

* 7. Was your Therapist/ Specialist attentive to your specific needs?

* 8. Overall, were you satisfied with quality of service you received?

* 9. Do you feel you received adequate information regarding your treatment and progress?

* 10. Were your rights as a patient communicated, and/or given to you in writing, prior to any treatment or service?

* 11. During the duration of your treatment, do you feel you were treated with dignity and respect?

* 12. Would you recommend MECA Therapies to your friends and/or family?

* 13. During the duration of your treatment, do you feel the environment was safe, comfortable and conducive to your needs- free from harassment, discrimination and/or hostile conditions?

* 14. Was the desired outcome achieved through the treatment you received?

* 15. Was your child at anytime assigned homework by his//her therapists?

* 16. Did you participate/assist your child with their homework assignments?

* 17. Were the homework assignments beneficial in helping your child's developmental progress?

Please rate the following items on a scale of 1-5 (1=very poor, 5=excellent). 

* 18. Availability of appointment times

* 19. Overall customer service from all MECA personnel

* 20. As a company, what are we doing well?

* 21. What can we do to improve?

Thank you for taking the time to fill out this survey. We wish you the best in all your future endeavors.

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