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Occupational Therapy Participant 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 you have 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 you are participating in:
(Required)
Occupational Therapy
Therapeutic Riding
Please describe your 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 your overall experience.
I feel safe when I participate in Hippotherapy/ Therapeutic Riding at Quantum Leap Farm.
(Required)
Strongly Agree
Agree
Neither Agree or Disagree
Disagree
Strongly Disagree
I feel that the goals set for me were purposeful, relevant, and attainable.
(Required)
Strongly Agree
Agree
Neither Agree or Disagree
Disagree
Strongly Disagree
I am very satisfied by the services I receive 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 during your time at Quantum Leap Farm.
How can we improve our services to you?
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
Events
Horse Play | Nov 3, 2023
Family Fun Days 2023
Holiday Bash | Dec 16, 2023
Stirrup Hope 2023 – Post Event
Colors of Courage 2023 – Post Event
Contact