MECA Therapies EXIT Survey Question Title * 1. Region: Las Cruces, New Mexico Clovis, New Mexico Roswell, New Mexico Hobbs, New Mexico Question Title * 2. What is the full name of the client? (First and Last) Question Title * 3. What is the full name of the parent/guardians of the client? (First and Last) Question Title * 4. What is the home address of the client? Question Title * 5. What is the primary contact number where the client can be reached? Question Title * 6. What type of therapy was the client seen for? Question Title * 7. Who was the clients Family Service Coordinator? Question Title * 8. What was the exit day of the client? This survey is indented to help identify ways MECA Therapies can improve as a company, and as a way to assess how satisfied you were with the services that were provided to you and 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. Please respond to the following questions as they pertain to your child and their treatment. Question Title * 9. Approximately how often did a MECA therapist or specialist see your child? Question Title * 10. Was your therapist/ specialist attentive to your specific needs? Yes No Question Title * 11. Please explain in further detail if your therapist/ specialist was NOT attentive to your specific needs. Question Title * 12. Overall, were you satisfied with the quality of service you and your child received? Yes No Question Title * 13. Please explain in further detail how the quality of service could have been better. Question Title * 14. Do you feel you received adequate information regarding your child's treatment and progress? Yes No Question Title * 15. Please explain in further detail why you were NOT satisfied with the amount of information received regarding your child's treatment and progress. Question Title * 16. Were your rights as a client communicated, and/or given to you in writing, prior to any treatment or service? Yes No I Don't Remember Question Title * 17. During the duration of your treatment, do you feel you were treated with dignity and respect? Yes No Question Title * 18. Please explain in further detail if you feel you were NOT treated with dignity and respect. Question Title * 19. Would you recommend MECA Therapies Early Intervention program to your friends and/or family? Yes No Question Title * 20. Please indicate why you would NOT want to recommend your friends and/ or family to MECA Therapies. Question Title * 21. 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? Yes No Question Title * 22. Was the desired outcome achieved through the treatment your child received? Yes No Question Title * 23. Please explain in further detail if your desired outcome was NOT achieved through the treatment your child received. Question Title * 24. Would you consider your transition from MECA's Early Childhood program into another program smooth and effective? Yes No This does not apply to my situation Question Title * 25. Please explain in further detail what could have gone better in the transition of programs. Please rate the following items on a scale of 1-5, (1=POOR and 5= EXCELLENT). Question Title * 26. In reference to scheduling appointments, how was the availability of appointment times? 1 2 3 4 5 Question Title * 27. How would you rate the overall customer service from all MECA personnel? 1 2 3 4 5 Question Title * 28. As a company, what are some things that we are doing well? Question Title * 29. What are some things we can improve on? Thank you for taking the time to fill out this survey. We wish you the best in all your future endeavors. Done
