Client Impact

Survey

To be completed by client at 3 month, 6 month, and 12 month intervals.

Date

Month

Day

Year

Pet's Name

Your Name

Phone

Email

Please rate your experience on a scale of 1–5

(1 = strongly disagree, 5 = strongly agree):

I participate more fully in family, community activities or life abilities.

I experience fewer episodes of anxiety, stress, isolation or exposure caused by my disability.

(Optional) Additional Comment:

Signature

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