National Pro Bono Rehabilitation Outcomes Collection Survey
Thank you for being part of our National Pro Bono Outcomes Collection. Your willingness to share will help us aggregate national outcomes from pro bono clinics across the country. Our ultimate goal is to utilize these outcomes to demonstrate the impact that pro bono rehabilitation services have on individuals and the medical profession as a whole.

Please report your outcomes in the categories noted below. If you have additional outcomes you'd like to report, please share in the open box at the end. If you need assistance determining how to collect outcomes, please contact Taylor Stone (taylorstone@movetogether.org) and she will connect you with someone who can assist you!

Please email ProBonoIncubator@movetogether.org if you have any questions or feedback. Thank you again!

Organization *
Your answer
Your name *
Your answer
Best email address for future correspondence *
Your answer
Reporting Period *
If you're not able to report outcomes from the noted timelines above, what are the dates of the outcomes that you're reporting? (ex: November 1, 2018 to February 23, 2019)
Your answer
Section 1: Outcomes Questions
Please report your outcomes for the period that you noted above (ex: January 1, 2019 to March 15, 2019)
Number of new clients evaluated or screened by the program in reporting period *
Your answer
Number of client visits in reporting period *
Your answer
Number of licensed rehabilitation professionals participating in direct client care (including but not limited to PT/PTA/OT/OTA licensed therapists/supervisors/faculty) *
Your answer
Number of student rehabilitation professionals participating in direct client care (including PT/PTA/OT/OTA students) *
Your answer
Section 2: Optional Questions
Please report your outcomes for the period that you noted above (ex: January 1, 2019 to March 15, 2019)
Can you please quantify why your clients are seeking pro bono care? This may include reasons such as: uninsured, ran out of visits, unable to afford co-pay, geographically relocated, etc. Please report as: reason/number, for example: uninsured/15 clients
Your answer
Cancel/no show rate
Your answer
Client demographics that are tracked (age, race, diagnosis, etc.)
Your answer
Amount of savings based on Medicare reimbursement (calculated based on units “billed”)
Your answer
Any other outcomes you'd like to share with us!
Your answer
Section 3: Share your stories!
Please share any stories that reflect how pro bono care has made an impact on clients, their families, or impacted those who provide care. We'd love to hear about them!
Add your stories here!
Your answer
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