Medical Transportation Scheduling and Satisfaction Survey
1.
First and Last Name
2.
What is the best time for you to be picked up for your appointments?
Morning (5 AM - 6 AM)
Morning (7 AM-8 AM)
Morning (9 AM- 10 AM)
Morning (11 AM)
3.
Do you have any work or other commitments that we should be aware of? Select all that apply.
Full-time work
Part-time work
School
Childcare
Other (please specify)
4.
Which days of the week do you attend individual counseling? Select all that apply.
Monday
Tuesday
Wednesday
Thursday
Friday
5.
Which days of the week do you attend group counseling? Select all that apply.
Monday
Tuesday
Wednesday
Thursday
Friday
6.
How satisfied are you with your current transportation company?
1 star
2 stars
3 stars
4 stars
5 stars
7.
Do you have any additional comments or suggestions regarding your transportation service?
