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1.
Your/Your Child's Therapist's Name:
2.
How old are you or your minor child?
0-9 years old - proceed Question
10-14 years old - process to Questio
15-19 years old - Begin with next question
20-29 years old
30-39 years old
40-49 years old
50-59 years old
60+ years old
3.
How long have you or your minor child been seeing this therapist?
1 Less than a month
2 One to three months
3 Four to six months
4 Six to twelve months
5 Over one year
4.
I feel my therapist understands me and my experiences / My child and I feel the therapist understands my child and his/her experiences
1 Strongly Disagree
2
3
4
5 Strongly Agree
5.
I feel that my therapist collaborates with me regarding my therapy / My child and I feel that his/her therapist collaborates with me and my child about his/her therapy
1 Strongly Disagree
2
3
4
5 Strongly Agree
6.
I feel helped by my therapist / My child & I feel s/he is being helped by the therapist
1 Strongly Disagree
2
2
4
5 Strongly Agree
7.
My therapist is sensitive to my racial and cultural identity / My child's therapist is sensitive to our racial and cultural identity
1 Strongly Disagree
2
3
4
5 Strongly Agree
8.
I feel that I can talk to my therapist about disagreements, frustrations, or concerns I have with him/her or the therapy / I feel my child and I can talk to his/her therapist about disagreements, frustrations, or concerns s/he or I have with the therapist or the therapy
1 Strongly Disagree
2
3
4
5 Strongly Agree
9.
I feel that my therapist is knowledgeable about the issues we talk about in therapy / My child and I feel that the therapist is knowledgeable about the issues addressed in the therapy
1 Strongly Disagree
2
3
4
5 Strongly Agree
10.
I trust my therapist
/ My child and I trust his/her therapist
1 Strongly Disagree
2
3
4
5 Strongly Agree
11.
Overall, I am satisfied with the clinical care provided by my therapist / Overall, my child and I are satisfied with the clinical care provided by my child's therapist
1 Strongly Disagree
2
3
4
5 Strongly Agree
12.
Please add any comments you would like to share about your therapist / your child's therapist
13.
The Presby Psych receptionist is respectful and professional
1 Strongly Disagree
2
3
4
5 Strongly Agree
14.
Making a first appointment with Presby Psych was a satisfactory experience
1 Strongly Disagree
2
3
4
5 Strongly Agree
15.
The initial Client Information paperwork at Presby Psych is reasonable
1 Strongly Disagree
2
3
4
5 Strongly Agree
16.
My questions about cancellation policies and other clinical policies are answered promptly and respectfully
1 Strongly Disagree
2
3
4
5 Strongly Agree
17.
The billing staff at Presby Psych is respectful and professional
1 Strongly Disagree
2
3
4
5 Strongly Agree
18.
I am satisfied with the financial statements I receive
1 Strongly Disagree
2
3
4
5 Strongly Agree
19.
My financial questions are answered accurately and respectfully
1 Yes
2 No
20.
Please add any comments you would like to share about our receptionist, paperwork, and/or billing staff
21.
Would you recommend Presby Psych to a friend or relative?
1 Yes
2 Maybe
3 No
Thank you for completing this survey.
Presbyterian Psychological Services
5203 Sharon Road
Charlotte, NC 28210
(704) 554-9900
www.presbypsych.org