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Occupational Therapy 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 Equine Assisted Therapy (Occupational Therapy).
Date
MM slash DD slash YYYY
Please identify which service your child is participating in:
(Required)
Occupational Therapy
Little Leapers Program - School Curriculum
Therapeutic Riding
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)
4 - Much Improvement
3 - Some Improvement
2 - No Change
1 - Decline
Independence:
(Required)
4 - Much Improvement
3 - Some Improvement
2 - No Change
1 - Decline
Self-Confidence:
(Required)
4 - Much Improvement
3 - Some Improvement
2 - No Change
1 - Decline
Overall Emotional Well-Being:
(Required)
4 - Much Improvement
3 - Some Improvement
2 - No Change
1 - Decline
Overall Physical Well-Being:
(Required)
4 - Much Improvement
3 - Some Improvement
2 - No Change
1 - Decline
Executive Functioning Skills (memory, organization, problem solving, emotional regulation):
(Required)
4 - Much Improvement
3 - Some Improvement
2 - No Change
1 - Decline
Activities of Daily Living (hand washing, dressing, grooming, feeding or cutting food):
(Required)
4 - Much Improvement
3 - Some Improvement
2 - No Change
1 - Decline
Core Strength, Balance & Postural Control throughout daily activities (increased sitting/standing tolerance, decreased fatigue):
(Required)
4 - Much Improvement
3 - Some Improvement
2 - No Change
1 - Decline
Fine Motor Skills throughout daily tasks/activities (coloring, tracing, writing, cutting, flipping pages in a book, fasteners):
(Required)
4 - Much Improvement
3 - Some Improvement
2 - No Change
1 - Decline
Communication Verbal/non-verbal (gestures, pointing, leading, vocalization, and/or use of devices and communication charts):
(Required)
4 - Much Improvement
3 - Some Improvement
2 - No Change
1 - Decline
Social Skills (engagement and participation in activities with family, friends, or peers):
(Required)
4 - Much Improvement
3 - Some Improvement
2 - No Change
1 - Decline
Sensory Processing integration of the environment (decreased self-stimulation, increased awareness):
(Required)
4 - Much Improvement
3 - Some Improvement
2 - No Change
1 - Decline
Proprioception body awareness and navigating across environmental surfaces (decreased tripping or leaning against things):
(Required)
4 - Much Improvement
3 - Some Improvement
2 - No Change
1 - Decline
Focus & Attention while following directions throughout daily living:
(Required)
4 - Much Improvement
3 - Some Improvement
2 - No Change
1 - Decline
Carry Over of Skills from the therapeutic session to their at home environment, school:
(Required)
4 - Much Improvement
3 - Some Improvement
2 - No Change
1 - Decline
Please pick the best response that describes the participant's overall experience.
I believe that when my child participates in Hippotherapy/ Therapeutic Riding at Quantum Leap Farm he/she is safe.
(Required)
Strongly Agree
Agree
Neither Agree or Disagree
Disagree
Strongly Disagree
I feel that the goals set for my child/ participant were purposeful, relevant, and attainable.
(Required)
Strongly Agree
Agree
Neither Agree or Disagree
Disagree
Strongly Disagree
I am very satisfied by the services my child/ participant receives at Quantum Leap Farm.
(Required)
Strongly Agree
Agree
Neither Agree or Disagree
Disagree
Strongly Disagree
Please tell us about any remarkable moments you have witnessed or experienced with your child/ the participant during your time at Quantum Leap Farm.
How can we improve our services to your child/ the participant or yourself?
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)
Yes
No
Contact me with more information (Please leave your name below)
Name
First
Last
Thank you from Quantum Leap Farm staff! Alexis Lopez, MOT, OTR/L Operations Director & Occupational Therapist
Close Menu
Support
Donate Today
Ways to Give
Volunteer
Partners
Donate a Horse
Donate Crypto Currency through BitPay
About
Mission
Staff
Horses & Farm Residents
Board of Directors
Financials
Services
Benefits of Participation
Therapeutic Riding
Hippotherapy
Warrior Mission: At Ease Military Retreats
EASE (EAGALA EAP/EAL)
Corporate Workshops
Military Programs
Visits, Tours & Other Programs
Stories
News Media
Testimonials
Events
Colors of Courage | Sep 14, 2023
Family Fun Days 2023
2023 Stirrup Hope – Post Event
Contact