DISCHARGE FEEDBACK FORM

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Thank you for being a part of our Jewel autism and child development center. Kindly take a few minutes to share your feedback regarding your child's therapy journey and discharge.

Parent Name *

Phone Number *

Child's Name *

Child's Age *

How long did your child receive services at Jewel autism and child development center? *

Less than 3 months

3 to 6 months

6 to 12 months

1 to 2 years

More than 2 years

Which services did your child receive? *

Have you noticed positive changes in your child during the therapy period? *

Yes

Who was the therapist who made the greatest positive impact on your child ? *

How satisfied are you with the appointment scheduling and coordination? *

Excellent

Good

Fair

Poor

What is the primary reason for discharge? *

Any additional suggestions or messages for our team? *

Submit

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