Patient Satisfaction Survey Question Title * 1. Who did you see today? (Provider Name) Question Title * 2. Date of Service Date / Time Date Question Title * 3. I feel welcome when entering the building. 1 - Very True 2 - Sometimes True 3 - Not True Question Title * 4. The waiting area and offices are clean. 1 - Very True 2 - Sometimes True 3 - Not True Question Title * 5. I feel safe in the waiting area and offices. 1 - Very True 2 - Sometimes True 3 - Not True Question Title * 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 Question Title * 7. The office space is sound proof so that I feel free to share. 1 - Very True 2 - Sometimes True 3 - Not True Question Title * 8. How would you rate the quality of service received? 1 - Excellent 2 - Good 3 - Fair 4 -Poor Question Title * 9. Did you get the kind of service you wanted? 1 - Yes, definitely 2 - Yes, generally 3 - Not really 4 - No, definitely not Question Title * 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 Question Title * 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 Question Title * 12. How can we improve your experience? Question Title * 13. How did you hear about or receive this survey? Select all that apply: My provider or therapist Front desk staff or reception Lobby signage or other print materials CCMHC website Social Media (Facebook, Instagram, etc.) Email or text message Other (please specify) 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. Question Title * 14. 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 Done
