Child Satisfaction Survey by Parent or Guardian

Your child and family are very important to us, and we work hard to insure that you are satisfied with our services and your treatment here.
Please take a moment to offer your feedback so that we may improve our services and offer everyone the best service possible. Thank you!

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* 1. Date

Date

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* 2. Age:

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* 3. Grade:

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* 4. How long have you been coming to the Clinic

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* 5. Please tell us the name of your child's therapist:

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* 6. Please tell us the name of your child's Psychiatrist/Nurse Practitioner:

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* 7. Please check the box which best describes how you feel:

  Strongly Agree Agree Neutral Disagree Strongly Disagree Does Not Apply
1. The Front Office staff were friendly, courteous, and professional.
2. The Front Office staff were helpful in scheduling my appointments.
3. I am satisfied with my child's therapist
4. My child's symptoms have improved.
5. The problems, that brought my child here, are getting better.
6. My child is doing better in school.
7. My child's behavior is improving.
8. My child is getting along better with family members.
9. I would recommend my child's therapist to family, friends, and others.
10. I am satisfied with my child's Psychiatrist/Nurse Practitioner.
11. My child's Psychiatrist/Nurse Practitioner tells us about my child's medications and possible side-effects.
12. My child's Psychiatrist/Nurse Practitioner answers our questions.
13. I would recommend my child's doctor/nurse practitioner to family, friends, and others.
14.I trust that the Clinic staff will maintain our confidentiality.
15. I would recommend this CLinic to family, friends, and others.

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* 8. Please tell us all the services the child receives at the Clinic:

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* 9. Please tell us your relationship to the child-client:

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* 10. Comments or Suggestions:

Thank You!  Your responses help us build a better program!

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