* 1. Client Name (Optional):

* 2. Therapy Service (PT, OT, SLP): 

* 3. Therapist (s): 

* 4. Relationship to client (Self, Parent, etc.):

Your satisfaction with the care you received during your visit to MECA Therapies is our highest priority. Please let us know how we are doing so that we can improve our services to you. Would you take a minute or two to complete this survey? Your ratings and comments are greatly appreciated. 
For each item identified below, select the option that best fits your judgement of its quality. Leave the line blank if you do not know or if thee line does not apply to you. 

* 5. How would you rank the courtesy of office personnel?

* 6. How would you rank the courtesy of the therapist?

* 7. How concerned was the therapists for your well being?

* 8. Did the therapists introduce themselves to you personally?

* 9. Was the evaluation and treatment you received adequately explained? ((i.e., expectations, time frames, etc.)

* 10. Were responses provided for your questions and concerns?

* 11. Was your dignity and feelings respected?

* 12. Was the therapist courteous, respectful and did they seem concerned about you?

* 13. Were appointments scheduled to your convenience?

* 14. Did the services begin promptly when you arrived for your appointment?

* 15. Did you trust and have confidence in your clinician?

* 16. Was the service and the attention consistent?

* 17. Did your therapist communicate with your doctor regarding the therapy process?

* 18. How would you rank the cleanliness of the facility?

* 19. How would you rank the atmosphere of the facility?

* 20. How would you rank the handling of insurance and billing by clinic staff?

* 21. How would you rank your overall impression of MECA Therapies?

* 22. What could we have done to make your visit better?

* 23. What did you like the most about MECA Therapies?

* 24. What did you like the least about MECA Therapies?

* 25. If any individual gave you outstanding attention, please let us know so we can commend that person. Also, if you would like to share some constructive criticism, let us know, and we will seek appropriate solutions.