* 1. Date of Visit

Date

* 2. Were you greeted promptly by front office staff?

* 3. Did you feel welcome and respected in the reception area?

* 4. Did you have an appointment?

* 5. If yes, were you seen within 10 minutes of your appointment time?

* 6. Did the case worker treat you with respect?

* 7. Was the case worker knowledgeable?

* 8. Did you receive assistance on the day you were seen?

* 9. If no, why not?

* 10. Comments/How can we better serve you?

T