Screen Reader Mode Icon Check SCREEN READER MODE to make this survey compatible with screen readers. Post-Visit Participant Satisfaction Question Title * 1. What is your gender? Woman Man Gender non-Conforming Other OK Question Title * 2. What city do you currently live in? OK Question Title * 3. How many people currently live in your household?' OK Question Title * 4. What is your total household income? Under $20,000 $20,001 to $44,999 $45,000 to $139,999 $140,000 to $149,999 Other (please specify) OK Question Title * 5. Overall, how satisfied or dissatisfied were you with your last visit to Genesis Programs Inc? Very satisfied Somewhat satisfied Neither satisfied nor dissatisfied Somewhat dissatisfied Very dissatisfied OK Question Title * 6. How easy or difficult was it to schedule an appointment at a time that was convenient for you? Very easy Somewhat easy Neither easy nor difficult Somewhat difficult Very difficult OK Question Title * 7. In your opinion, how convenient is the location of our Facility? Extremely convenient Very convenient Somewhat convenient Not so convenient Not at all convenient OK Question Title * 8. Please indicate your level of satisfaction with the following items related to the Receptionist. Very satisfied Satisfied Neither satisfied nor dissatisfied Dissatisfied Very Dissatisfied Welcoming Welcoming Very satisfied Welcoming Satisfied Welcoming Neither satisfied nor dissatisfied Welcoming Dissatisfied Welcoming Very Dissatisfied Professionalism Professionalism Very satisfied Professionalism Satisfied Professionalism Neither satisfied nor dissatisfied Professionalism Dissatisfied Professionalism Very Dissatisfied Attentiveness Attentiveness Very satisfied Attentiveness Satisfied Attentiveness Neither satisfied nor dissatisfied Attentiveness Dissatisfied Attentiveness Very Dissatisfied Friendliness and Courtesy Friendliness and Courtesy Very satisfied Friendliness and Courtesy Satisfied Friendliness and Courtesy Neither satisfied nor dissatisfied Friendliness and Courtesy Dissatisfied Friendliness and Courtesy Very Dissatisfied Overall Customer Service Experience Overall Customer Service Experience Very satisfied Overall Customer Service Experience Satisfied Overall Customer Service Experience Neither satisfied nor dissatisfied Overall Customer Service Experience Dissatisfied Overall Customer Service Experience Very Dissatisfied OK Question Title * 9. How comfortable was the lobby and waiting area? Extremely comfortable Very comfortable Somewhat comfortable Not so comfortable Not at all comfortable OK Question Title * 10. Was your appointment with the Staff within the time frame originally quoted? Yes No Late OK Question Title * 11. How well did the Counselor listen to your needs? Extremely well Very well Somewhat well Not so well Not at all well OK Question Title * 12. How well did the Counselor answer your questions? Extremely well Very well Somewhat well Not so well Not at all well OK Question Title * 13. How well did the Counselor explain your treatment options? Extremely well Very well Somewhat well Not so well Not at all well OK Question Title * 14. How satisfied were you with the Counselor explanation to your follow-up care? Extremely satisfied Very satisfied Somewhat satisfied Not so satisfied Not at all satisfied OK Question Title * 15. How much do you trust the recommendations of the Counselor? A great deal of trust A lot of trust A moderate amount of trust A little trust Not any trust at all OK Question Title * 16. How satisfied or dissatisfied were you with the amount of time the Counselor spent with you addressing your needs? Very satisfied Somewhat satisfied Neither satisfied nor dissatisfied Somewhat dissatisfied Very dissatisfied OK Question Title * 17. Overall, how would you rate the care you received from the Counselor? Excellent Very good Good Fair Poor OK Question Title * 18. How likely is it that you would recommend our Treatment Program to a friend or family member? NOT AT ALL LIKELY EXTREMELY LIKELY 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 OK Question Title * 19. Is there anything we could have done to improve your last visit? OK DONE
