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Hippotherapy Parent/Caregiver Satisfaction Survey

Thank you for participating in therapy at Quantum Leap Farm. We would appreciate if you would take a few minutes to tell us how the participant/your child has improved over the last 6-12 months since participating in Hippotherapy.

MM slash DD slash YYYY
Please identify which service your child is participating in:(Required)

Please describe the participant's improvements/abilities since participating in therapy at Quantum Leap Farm.

4 = Much Improvement 3 = Some Improvement 2 = No Change 1 = Decline
Quality of Life:(Required)
Independence:(Required)
Self-Confidence:(Required)
Overall Emotional Well-Being:(Required)
Overall Physical Well-Being:(Required)
Executive Functioning Skills (memory, organization, problem solving, emotional regulation):(Required)
Activities of Daily Living (hand washing, dressing, grooming, feeding or cutting food):(Required)
Core Strength, Balance & Postural Control throughout daily activities (increased sitting/standing tolerance, decreased fatigue):(Required)
Fine Motor Skills throughout daily tasks/activities (coloring, tracing, writing, cutting, flipping pages in a book, fasteners):(Required)
Communication Verbal/non-verbal (gestures, pointing, leading, vocalization, and/or use of devices and communication charts):(Required)
Receptive Language (understanding what is said to him/her):(Required)
Social Skills (engagement and participation in activities with family, friends, or peers):(Required)
Sensory Processing integration of the environment (decreased self-stimulation, increased awareness):(Required)
Proprioception body awareness and navigating across environmental surfaces (decreased tripping or leaning against things):(Required)
Focus & Attention while following directions throughout daily living:(Required)
Carry Over of Skills from the therapeutic session to their at home environment, school:(Required)

Please pick the best response that describes the participant's overall experience.

I believe that when my child participates in Hippotherapy at Quantum Leap Farm they are safe.(Required)
I feel that the goals set for my child/ participant were purposeful, relevant, and attainable.(Required)
I am very satisfied by the services my child/ participant receives at Quantum Leap Farm.(Required)
Are you willing to share your story/ experience with QLF marketing staff to share on social media or other networking platforms? If so please provide name below or contact us privately.(Required)
Name

Thank you from Quantum Leap Farm staff!

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