Referral Source / Stakeholder Survey - Waters & Sims

Question Title

* Todays Date

Date

Date

Question Title

* REFERRALS

	Strongly Agree	Agree	Disagree	Strongly Disagree	N/A
1. When I have referred someone to this organization, I believe that they were given an appointment within a reasonable time.	1. When I have referred someone to this organization, I believe that they were given an appointment within a reasonable time. Strongly Agree	1. When I have referred someone to this organization, I believe that they were given an appointment within a reasonable time. Agree	1. When I have referred someone to this organization, I believe that they were given an appointment within a reasonable time. Disagree	1. When I have referred someone to this organization, I believe that they were given an appointment within a reasonable time. Strongly Disagree	1. When I have referred someone to this organization, I believe that they were given an appointment within a reasonable time. N/A

Question Title

* COMMUNICATION

	Strongly Agree	Agree	Disagree	Strongly Disagree	N/A
2. When I last telephoned, the call was answered in a courteous manner.	2. When I last telephoned, the call was answered in a courteous manner. Strongly Agree	2. When I last telephoned, the call was answered in a courteous manner. Agree	2. When I last telephoned, the call was answered in a courteous manner. Disagree	2. When I last telephoned, the call was answered in a courteous manner. Strongly Disagree	2. When I last telephoned, the call was answered in a courteous manner. N/A
3. My calls/emails to staff are returned promptly.	3. My calls/emails to staff are returned promptly. Strongly Agree	3. My calls/emails to staff are returned promptly. Agree	3. My calls/emails to staff are returned promptly. Disagree	3. My calls/emails to staff are returned promptly. Strongly Disagree	3. My calls/emails to staff are returned promptly. N/A
4. Staff is responsive to my inquiries or concerns.	4. Staff is responsive to my inquiries or concerns. Strongly Agree	4. Staff is responsive to my inquiries or concerns. Agree	4. Staff is responsive to my inquiries or concerns. Disagree	4. Staff is responsive to my inquiries or concerns. Strongly Disagree	4. Staff is responsive to my inquiries or concerns. N/A
5. Staff provides timely feedback with consumer updates.	5. Staff provides timely feedback with consumer updates. Strongly Agree	5. Staff provides timely feedback with consumer updates. Agree	5. Staff provides timely feedback with consumer updates. Disagree	5. Staff provides timely feedback with consumer updates. Strongly Disagree	5. Staff provides timely feedback with consumer updates. N/A

Question Title

* SERVICES

	Strongly Agree	Agree	Disagree	Strongly Disagree	N/A
8. Services received from the staff of this organization meet the needs of individuals being served.	8. Services received from the staff of this organization meet the needs of individuals being served. Strongly Agree	8. Services received from the staff of this organization meet the needs of individuals being served. Agree	8. Services received from the staff of this organization meet the needs of individuals being served. Disagree	8. Services received from the staff of this organization meet the needs of individuals being served. Strongly Disagree	8. Services received from the staff of this organization meet the needs of individuals being served. N/A
9. Staff help individuals that I have referred obtain the right kind of service for their problem(s).	9. Staff help individuals that I have referred obtain the right kind of service for their problem(s). Strongly Agree	9. Staff help individuals that I have referred obtain the right kind of service for their problem(s). Agree	9. Staff help individuals that I have referred obtain the right kind of service for their problem(s). Disagree	9. Staff help individuals that I have referred obtain the right kind of service for their problem(s). Strongly Disagree	9. Staff help individuals that I have referred obtain the right kind of service for their problem(s). N/A
10. Staff have been courteous, knowledgeable, and helpful.	10. Staff have been courteous, knowledgeable, and helpful. Strongly Agree	10. Staff have been courteous, knowledgeable, and helpful. Agree	10. Staff have been courteous, knowledgeable, and helpful. Disagree	10. Staff have been courteous, knowledgeable, and helpful. Strongly Disagree	10. Staff have been courteous, knowledgeable, and helpful. N/A

Question Title

* OVERALL SATISFACTION

	Strongly Agree	Agree	Disagree	Strongly Disagree	N/A
11. In general, I have been satisfied with the services provided by this organization.	11. In general, I have been satisfied with the services provided by this organization. Strongly Agree	11. In general, I have been satisfied with the services provided by this organization. Agree	11. In general, I have been satisfied with the services provided by this organization. Disagree	11. In general, I have been satisfied with the services provided by this organization. Strongly Disagree	11. In general, I have been satisfied with the services provided by this organization. N/A

Question Title

* COMMENTS:

Question Title

* Name / Phone / email (OPTIONAL)

Name

Organization

Phone

Email

Date

Question Title

* Follow-up

I would like to receive a follow-up phone call from the organization. (Name and phone number must be provided above.)