Date of Visit:
Please indicate the type of service you are receiving: TherapyEvaluation/ testingOther (administrative interactions)
Please answer the following questions about your experience:
To what extent did your provider:
Help you achieve the purpose for which you sought services?
Help you obtain skills that will help you handle future problems?
Show interest in your needs?
Understand your needs?
Help you define your needs?
Involve you in the treatment planning (such as treatment goals and frequency of appointments)?
Respond to your requests for services?
Treat you with dignity and respect?
Please rate the efficiency and accuracy with which your scheduling and billing process occurred:
Are you going to continue treatment with this therapist or would you return to your provider for services in the future if needed? YesNo
Do you have any specific concerns or complaints about your treatment? If so, please explain below. YesNo
Are there some things you feel were especially good or helpful about your treatment? If so, please explain below YesNo
Please explain/additional comments:
By checking here, I give permission for my feedback to be posted anonymously to our internal staff morale board in the office. Our staff love hearing how they are helping to make a difference!
