Wufoo

Resources for Autism Evaluation Form

To make sure that the service you are receiving from Resources for Autism is meeting your needs please complete this form. You may be asked to do so more than once but it helps us to continue to develop services and evidence our need for funding. You may write as much or as little as you like where there is an open question. If you would like a version in symbol form or need help just call the office on 02084583259. Information will only be used to help us develop and improve our services.

Name of person completing the questionnaire
Name of service user
Date MM / DD / YYYY
Service(s) Used
Weekend Play London Weekend Play B'ham Evening Youth Club London Evening Youth Club B'ham Holiday Play London Holiday Play B'ham Siblings Group London Siblings Group B'ham Reach Out Home Support London Reach Out Home Support B'ham Music Therapy Art Therapy Adult Groups
If the service was at a play/youth venue or adult group please state which one. (Barnet, St Pauls, Ufflecume etc)
Did user enjoy the service?
Strongly Agree Agree Disagree Strongly Disagree
Did user benefit from the service?
Strongly agree Agree Disagree Strongly Disagree
We would like to know in what way the service was useful in more detail. For one week holiday play some may not apply whereas they may be very relevant to a therapy place. Please Just complete all those that apply.
Making relationships/friendships
Improved Significantly Improved a little Did not improve at all Not applicable
Independence (including travel on public transport/transitions etc)
Improved significantly Improved a little Did not improve at all Not applicable
Communication
Improved significantly Improved a little Did not improve at all Not applicable
Interaction
Improved significantly Improved a little Did not improve at all Not applicable
Play Skills (including turn taking, sharing etc)
Improved significantly Improved a little Did not improve at all Not applicable
Skills (Ability to try/do new things)
Improved significantly Improved a little Did not improve at all Not applicable
Self confidence
Improved significantly Improved a little Did not improve at all Not applicable
Concentration
Improved significantly Improved a little Did not improve at all Not applicable
Mood (happier, less anxious, more relaxed)
Improved significantly Improved a little Did not improve at all Not applicable
Other; Please describe
Overall the service met users needs
Strongly agree Agree Disagree Strongly disagree
I was given enough feedback
Strongly Agree Agree Disagree Strongly Disagree
The service has benefited parent/carer/family
Strongly Agree Agree Disagree Strongly Disagree
What did you most like about the service you used?
What would you have liked to be different or what could we do better?
How would you rate value for money?
Excellent Good Adequate Poor It was a free service
Have you received helpful information from RfA?
Yes No None given
Thank you for completing this. When you have finished it will automatically come back to the Director at RfA and information will be detached from your name before it is stored. Any individual issues raised will be addressed with the relevent staff to ensure continued improvement in service.
Do Not Fill This Out

Wufoo

We would like to know in what way the service was useful in more detail. For one week holiday play some may not apply whereas they may be very relevant to a therapy place. Please Just complete all those that apply.

Thank you for completing this. When you have finished it will automatically come back to the Director at RfA and information will be detached from your name before it is stored. Any individual issues raised will be addressed with the relevent staff to ensure continued improvement in service.