Patient Satisfaction Survey

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* 1. Who did you see today? (Provider Name)

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* 2. Date of Service

Date / Time

Date

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* 3. I feel welcome when entering the building.

1 - Very True

2 - Sometimes True

3 - Not True

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* 4. The waiting area and offices are clean.

1 - Very True

2 - Sometimes True

3 - Not True

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* 5. I feel safe in the waiting area and offices.

1 - Very True

2 - Sometimes True

3 - Not True

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* 6. The waiting area had information, posters, images, or artwork that are inclusive of my culture, ethnicity, or identity.

1 - Very True

2 - Sometimes True

3 - Not True

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* 7. The office space is sound proof so that I feel free to share.

1 - Very True

2 - Sometimes True

3 - Not True

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* 8. How would you rate the quality of service received?

1 - Excellent

2 - Good

3 - Fair

4 -Poor

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* 9. Did you get the kind of service you wanted?

1 - Yes, definitely

2 - Yes, generally

3 - Not really

4 - No, definitely not

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* 10. Have the services you received helped you deal more effectively with your problem(s)?

1 - Yes, they helped a great deal

2 - Yes, they helped

3 - No, they didn't really help

4 - No, they seemed to make things worse

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* 11. If a friend were in need of similar help, would you recommend our programs to them?

1 - Yes, definitely

2 - Yes, I think so

3 - I don't think so

4 - No, definitely not

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* 12. How can we improve your experience?

Did an employee or provider go above and beyond in their service to you during your visit?

Follow this link: https://forms.office.com/r/BW27iTP5Sj and give them a "Shout-Out!" We will pass your words along to our employees. Do not forget to return to this page and submit your survey.

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* 13. If you would like your name to be entered to win a $25 gift card for completing this survey, please include your information below.

Name

Phone Number