707-228-0679

VETERANS WITH PTSD

707-228-0679

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PTSD

Home
About
Surf Dogs
Swimming Dogs
Healing Dogs
Assistance Dogs
Programs
PTSD

SWIMMING SURVEY 2

(after 3rd canine-assisted swimming lesson)

Your information will only be used internally, and will not be shared with any third party. We will extrapolate statistics from all questionnaires we receive in an effort to afford your child the best swim lesson experience possible. We will also use our statistics to provide data to grantors.

Please complete the questions below:

* Indicates required field

Today's date *

Your name *

First

Last

Email *

What is your child's name? *

Please rate your child’s abilities in the following areas:

Swimming *

High Above average Average Below average Low

Sense of water safety *

High Above average Average Below average Low

Trust *

High Above average Average Below average Low

Self esteem *

High Above average Average Below average Low

Confidence *

High Above average Average Below average Low

Positive mood/affect *

High above average Average Below average Low

Calm *

High Above average Average Below average Low

Focused *

High Above average Average Below average Low

Social interactions *

High Above average Average Below average Low

Connection to others *

High Above average Average Below average Low

Likes animals *

High Above average Average Below average Low

Expresses emotion *

High Above average Average Below average Low

Follows direction *

High Above average Average Below average Low

Cooperative *

High Above average Average Below average Low

Motivated *

High Above average Average Below average Low

Enthusiastic *

High Above average Average Below average Low

Compliant *

High Above average Average Below average Low

Responsive *

High Above average Average Below average Low

Ability to learn *

High Above average Average Below average Low

Speech *

High Above average Average Below average Low

Physical strength *

High Above average Average Below average Low

Motor function *

High Above average Average Below average Low

Sensory sensitivity *

High Above average Average Below average Low

Hyperactivity *

High Above average Average Below average Low

Attention *

High Above average Average Below average Low

Concentration *

High Above average Average Below average Low

Cognitive function *

High Above average Average Below average Low

Communication *

High Above average Average Below average Low

Distractibility *

High Above average Average Below average Low

Depression *

High Above average Average Below average Low

Anxiety *

High Above average Average Below average Low

Fearful *

High Above average Average Below average Low

Please check all that apply

My child: *

Is afraid of water Needs full assistance in water Enters water using ladder/steps Exits water using ladder/steps Stands waist deep in water Stands and holds wall/ladder Stands along wall w/o touching Walks in water while holding wall Pushes off wall Uses arms to propel forward Submerges mouth Submerges nose Submerges eyes Submerges entire head Blows bubbles from mouth Blows bubbles from nose Opens eyes under water Bobs up and down in the water Floats on front with support Floats on front without support

My child: *

Floats on back with support Floats on back without support Rolls from back/front to back/front Picks up submerged object with eyes open Swims under water Jumps into shoulder deep water Jumps into water over their head Jumps into water from the side Treads water Does breast strokes Does butterfly Wears mask under water Wears goggles under water Is ok with getting hair wet Is okay with full head under water Holds breath under water Kicks their legs Moves arms and legs together in water Swim independently Swims more than 15 feet in the pool

Please answer the following questions

Do you believe the dog:

Made a difference in your child’s swim lessons? *

Yes No

Deepened trust between your child and swim instructor? *

Yes No

Made an emotional connection with your child? *

Yes No

Broke down barriers between your child and the swim instructor? *

Yes No

Encouraged bonding? *

Yes No

Provided a meaningful distraction? *

Yes No

Provided comfort? *

Yes No

Helped your child feel safer? *

Yes No

Increased your child’s verbalization? *

Yes No

Increased your child’s socialization? *

Yes No

Did your child have a sensory enrichment experience? *

Yes No

Brightened your child’s affect and mood? *

Yes No

Are you satisfied with the work of the dog? *

Yes No

Did you understand what the dog was trying to communicate? *

Yes No

Have you noticed the benefits of canine-assisted swim lessons overflow to other areas of daily living? *

Yes No

Were you satisfied with the pool? *

Yes No

Were you satisfied with the environment? *

Yes No

Were you satisfied with the location? *

Yes No

Do you prefer a public pool vs our private home pool? *

Yes No

Did our Zen environment create relaxation and calmness for your child? *

Yes No

Have the canine-assisted swim lessons met your expectations? *

Yes No

Did your child enjoy our sensory play room? *

Yes No

What comments has your child made about the last three weeks of canine-assisted swimming? *

Do you have anything else you'd like to add, or suggestions for how to improve our canine-assisted swim lessons? *

Thank you so much for your help. Our goal is to make your child's swim lesson the most individualized possible.

THE SUBMIT BUTTON IS RIGHT ABOVE THIS LINE. UNFORTUNATELY IT'S IN BLACK & HARD TO SEE. SORRY!

Survey 2