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Surveyadmin2021-11-10T20:29:56+00:00

Satisfaction Survey

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 counseling?

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?

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?
YesNo

Are there some things you feel were especially good or helpful about your treatment?
YesNo

Please rate the efficiency and accuracy with which your scheduling and billing process occurred:

Please explain/additional comments:

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Therapy Request Form

Contact Information

First Name

Last Name

Preferred Name

Date of Birth

Legal Sex
FemaleMaleNonbinary

Gender Identity

Preferred Pronouns

Address

City

State

Zip

County

Phone Number

Click for consent terms in providing mobile information

Your Email

Parent or Emergency Contact Name

Click for consent terms in providing mobile information

Parent or Emergency Contact Phone Number

Relationship to Contact Listed Above

Insurance

Primary Insurance Provider

Member ID Number

Secondary Insurance Provider

Member ID Number

Clinical

What type of therapy are you seeking?
ERPEMDRIndividualPCITPlay AttentionFamilyOther
[group therapy-type-other inline] Specify therapy type:[/group]

What are your concerns and goals for therapy?

Are you requesting therapy with a specific clinician at PPLLC?
YesNo

What are your concerns and goals for therapy?

Availability

Do you prefer in-person or virtual appointments?
In-PersonVirtualNo Preference

What days are you available for an appointment?
MondayTuesdayWednesdayThursdayFriday

Do you have a time preference?
MorningAfternoonEveningOther
[group time-preference-other inline] Specify time preference:[/group]

How did you hear about us?
Insurance CompanyPCPPsychological Perspectives websitePsychology TodayRecommended by a friendSchool DistrictSearch Engine (Google, Yahoo, Etc.)Social MediaOther
[group hear-about-other inline]Specify how you heard about us/ who referred you.[/group]

[group group-sms-accept]
By choosing to provide your mobile information, you agree to receive SMS text messages from us related to services that we are providing to you (such as for the purposes of scheduling, rescheduling, and/or appointment reminders). Messaging frequency may vary. Messaging and data rates may apply. Your mobile information will not be shared with any third parties/affiliates for marketing/promotional purposes, and all Protected Health Information (PHI) is stored in a HIPAA compliant platform. All policies are followed as per CTIA guidelines 5.2.1. Text STOP at any time to opt out of receiving SMS text messages or HELP for assistance. If at any time you want your information to be removed, or if you have any privacy related queries, you can contact us via our email address at [email protected] or regular mail at 345 Regis Ave. Suite 2 Pittsburgh, PA 15236.

[/group]

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Submit," you agree to hold Psychological Perspectives LLC harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Testing Intake Request Form

Contact Information

First Name

Last Name

Date of Birth

FemaleMaleNonbinary

Gender Identity

Preferred Pronouns

Address

City

State

Zip

County

Phone Number

Click for consent terms in providing mobile information

Your Email

Parent or Emergency Contact Name

Parent or Emergency Contact Phone Number

Click for consent terms in providing mobile information

Relationship to Contact Listed Above

Insurance

Primary Insurance Provider

Member ID Number

Secondary Insurance Provider

Member ID Number

Clinical

What type of testing are you seeking?

What are your primary concerns?

Have you had psychological/ neuropsychological testing in the past?
YesNo

If yes, what was the name of the evaluator / office and date of evaluation?

Availability

What days are you available for an intake appointment?
MondayTuesdayWednesdayThursdayOther
[group availability-other inline] Specify days available:[/group]

Do you have a time preference?
MorningAfternoonOther
[group time-preference-other inline] Specify time preference:[/group]

How did you hear about us?
Insurance CompanyPCPPsychological Perspectives websitePsychology TodayRecommended by a friendSchool DistrictSearch Engine (Google, Yahoo, Etc.)Social MediaOther
[group thear-about-other inline]Specify how you heard about us/ who referred you.[/group]

[group group-sms-accept]
By choosing to provide your mobile information, you agree to receive SMS text messages from us related to services that we are providing to you (such as for the purposes of scheduling, rescheduling, and/or appointment reminders). Messaging frequency may vary. Messaging and data rates may apply. Your mobile information will not be shared with any third parties/affiliates for marketing/promotional purposes, and all Protected Health Information (PHI) is stored in a HIPAA compliant platform. All policies are followed as per CTIA guidelines 5.2.1. Text STOP at any time to opt out of receiving SMS text messages or HELP for assistance. If at any time you want your information to be removed, or if you have any privacy related queries, you can contact us via our email address at [email protected] or regular mail at 345 Regis Ave. Suite 2 Pittsburgh, PA 15236.

[/group]

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Submit," you agree to hold Psychological Perspectives LLC harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

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