Therapy Survey - Therapist

See Variety email for therapy period end date
Enter the name of the clinic below.
First and last name

Skills

Select all that apply. If you have more than one area that falls under 'Other', select an Other option below for each area.
Select all that apply. If you have more than one area that falls under 'Other', select an Other option below for each area.
Select all that apply. If you have more than one area that falls under 'Other', select an Other option below for each area.
Select all that apply. If you have more than one area that falls under 'Other', select an Other option below for each area.
Select all that apply. If you have more than one area that falls under 'Other', select an Other option below for each area.
Select all that apply. If you have more than one area that falls under 'Other', select an Other option below for each area.
Select all that apply. If you have more than one area that falls under 'Other', select an Other option below for each area.
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or More
Baseline
Current
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or More
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or More
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or More
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or More
Baseline
Current
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or More
Baseline
Current
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or More
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or More
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or More
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or More
Baseline
Current
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or More
Baseline
Current
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or More
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or More
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or More
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or More
Baseline
Current
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Enter description of other area of treatment
Mild: 0 - 24% DelayModerate: 25 - 49% DelaySevere: Delay of 50% or more
Baseline
Current
Please list reason for any absences

Long Term Goals - Independence

Short Term Goals - Skills