Satisfaction Survey

Please share your review of the services you received. Note that your survey will remain confidential unless you would like to provide your name and contact information for further discussion about your treatment. We do our best to ensure our clients have quality care, and we appreciate your feedback.

	Excellent	Very Good	Fair	Poor	Terrible	N/A
Ease of making appointments	Ease of making appointments Excellent	Ease of making appointments Very Good	Ease of making appointments Fair	Ease of making appointments Poor	Ease of making appointments Terrible	Ease of making appointments N/A
Appointment available within a reasonable amount of time	Appointment available within a reasonable amount of time Excellent	Appointment available within a reasonable amount of time Very Good	Appointment available within a reasonable amount of time Fair	Appointment available within a reasonable amount of time Poor	Appointment available within a reasonable amount of time Terrible	Appointment available within a reasonable amount of time N/A
Waiting time in the reception area	Waiting time in the reception area Excellent	Waiting time in the reception area Very Good	Waiting time in the reception area Fair	Waiting time in the reception area Poor	Waiting time in the reception area Terrible	Waiting time in the reception area N/A
Staff checked on you and offered assistance	Staff checked on you and offered assistance Excellent	Staff checked on you and offered assistance Very Good	Staff checked on you and offered assistance Fair	Staff checked on you and offered assistance Poor	Staff checked on you and offered assistance Terrible	Staff checked on you and offered assistance N/A
Ease of getting a referral when you needed one	Ease of getting a referral when you needed one Excellent	Ease of getting a referral when you needed one Very Good	Ease of getting a referral when you needed one Fair	Ease of getting a referral when you needed one Poor	Ease of getting a referral when you needed one Terrible	Ease of getting a referral when you needed one N/A

Excellent

Very Good

Fair

Poor

Terrible

N/A

Ease of making appointments

Ease of making appointments Excellent

Ease of making appointments Very Good

Ease of making appointments Fair

Ease of making appointments Poor

Ease of making appointments Terrible

Ease of making appointments N/A

Appointment available within a reasonable amount of time

Appointment available within a reasonable amount of time Excellent

Appointment available within a reasonable amount of time Very Good

Appointment available within a reasonable amount of time Fair

Appointment available within a reasonable amount of time Poor

Appointment available within a reasonable amount of time Terrible

Appointment available within a reasonable amount of time N/A

Waiting time in the reception area

Waiting time in the reception area Excellent

Waiting time in the reception area Very Good

Waiting time in the reception area Fair

Waiting time in the reception area Poor

Waiting time in the reception area Terrible

Waiting time in the reception area N/A

Staff checked on you and offered assistance

Staff checked on you and offered assistance Excellent

Staff checked on you and offered assistance Very Good

Staff checked on you and offered assistance Fair

Staff checked on you and offered assistance Poor

Staff checked on you and offered assistance Terrible

Staff checked on you and offered assistance N/A

Ease of getting a referral when you needed one

Ease of getting a referral when you needed one Excellent

Ease of getting a referral when you needed one Very Good

Ease of getting a referral when you needed one Fair

Ease of getting a referral when you needed one Poor

Ease of getting a referral when you needed one Terrible

Ease of getting a referral when you needed one N/A

	Excellent	Very Good	Fair	Poor	Terrible	N/A
The friendliness and courtesy of the office staff	The friendliness and courtesy of the office staff Excellent	The friendliness and courtesy of the office staff Very Good	The friendliness and courtesy of the office staff Fair	The friendliness and courtesy of the office staff Poor	The friendliness and courtesy of the office staff Terrible	The friendliness and courtesy of the office staff N/A
The professionalism of our staff	The professionalism of our staff Excellent	The professionalism of our staff Very Good	The professionalism of our staff Fair	The professionalism of our staff Poor	The professionalism of our staff Terrible	The professionalism of our staff N/A
Getting advice or help when needed during office hours	Getting advice or help when needed during office hours Excellent	Getting advice or help when needed during office hours Very Good	Getting advice or help when needed during office hours Fair	Getting advice or help when needed during office hours Poor	Getting advice or help when needed during office hours Terrible	Getting advice or help when needed during office hours N/A
Our ability to return your calls in a timely manner	Our ability to return your calls in a timely manner Excellent	Our ability to return your calls in a timely manner Very Good	Our ability to return your calls in a timely manner Fair	Our ability to return your calls in a timely manner Poor	Our ability to return your calls in a timely manner Terrible	Our ability to return your calls in a timely manner N/A
Your ability to obtain medication	Your ability to obtain medication Excellent	Your ability to obtain medication Very Good	Your ability to obtain medication Fair	Your ability to obtain medication Poor	Your ability to obtain medication Terrible	Your ability to obtain medication N/A
The quality of your care	The quality of your care Excellent	The quality of your care Very Good	The quality of your care Fair	The quality of your care Poor	The quality of your care Terrible	The quality of your care N/A

Excellent

Very Good

Fair

Poor

Terrible

N/A

The friendliness and courtesy of the office staff

The friendliness and courtesy of the office staff Excellent

The friendliness and courtesy of the office staff Very Good

The friendliness and courtesy of the office staff Fair

The friendliness and courtesy of the office staff Poor

The friendliness and courtesy of the office staff Terrible

The friendliness and courtesy of the office staff N/A

The professionalism of our staff

The professionalism of our staff Excellent

The professionalism of our staff Very Good

The professionalism of our staff Fair

The professionalism of our staff Poor

The professionalism of our staff Terrible

The professionalism of our staff N/A

Getting advice or help when needed during office hours

Getting advice or help when needed during office hours Excellent

Getting advice or help when needed during office hours Very Good

Getting advice or help when needed during office hours Fair

Getting advice or help when needed during office hours Poor

Getting advice or help when needed during office hours Terrible

Getting advice or help when needed during office hours N/A

Our ability to return your calls in a timely manner

Our ability to return your calls in a timely manner Excellent

Our ability to return your calls in a timely manner Very Good

Our ability to return your calls in a timely manner Fair

Our ability to return your calls in a timely manner Poor

Our ability to return your calls in a timely manner Terrible

Our ability to return your calls in a timely manner N/A

Your ability to obtain medication

Your ability to obtain medication Excellent

Your ability to obtain medication Very Good

Your ability to obtain medication Fair

Your ability to obtain medication Poor

Your ability to obtain medication Terrible

Your ability to obtain medication N/A

The quality of your care

The quality of your care Excellent

The quality of your care Very Good

The quality of your care Fair

The quality of your care Poor

The quality of your care Terrible

The quality of your care N/A

	Excellent	Very Good	Fair	Poor	Terrible	N/A
Willingness to listen carefully to you	Willingness to listen carefully to you Excellent	Willingness to listen carefully to you Very Good	Willingness to listen carefully to you Fair	Willingness to listen carefully to you Poor	Willingness to listen carefully to you Terrible	Willingness to listen carefully to you N/A
Taking time to answer your questions	Taking time to answer your questions Excellent	Taking time to answer your questions Very Good	Taking time to answer your questions Fair	Taking time to answer your questions Poor	Taking time to answer your questions Terrible	Taking time to answer your questions N/A
Involved you in the treatment planning (such as setting goals and frequency of appointments)	Involved you in the treatment planning (such as setting goals and frequency of appointments) Excellent	Involved you in the treatment planning (such as setting goals and frequency of appointments) Very Good	Involved you in the treatment planning (such as setting goals and frequency of appointments) Fair	Involved you in the treatment planning (such as setting goals and frequency of appointments) Poor	Involved you in the treatment planning (such as setting goals and frequency of appointments) Terrible	Involved you in the treatment planning (such as setting goals and frequency of appointments) N/A
Helped you achieve the purpose for which you sought services	Helped you achieve the purpose for which you sought services Excellent	Helped you achieve the purpose for which you sought services Very Good	Helped you achieve the purpose for which you sought services Fair	Helped you achieve the purpose for which you sought services Poor	Helped you achieve the purpose for which you sought services Terrible	Helped you achieve the purpose for which you sought services N/A
Taught skills that will help you handle future problems	Taught skills that will help you handle future problems Excellent	Taught skills that will help you handle future problems Very Good	Taught skills that will help you handle future problems Fair	Taught skills that will help you handle future problems Poor	Taught skills that will help you handle future problems Terrible	Taught skills that will help you handle future problems N/A
Provided an opportunity to make lasting meaningful change	Provided an opportunity to make lasting meaningful change Excellent	Provided an opportunity to make lasting meaningful change Very Good	Provided an opportunity to make lasting meaningful change Fair	Provided an opportunity to make lasting meaningful change Poor	Provided an opportunity to make lasting meaningful change Terrible	Provided an opportunity to make lasting meaningful change N/A

Excellent

Very Good

Fair

Poor

Terrible

N/A

Willingness to listen carefully to you

Willingness to listen carefully to you Excellent

Willingness to listen carefully to you Very Good

Willingness to listen carefully to you Fair

Willingness to listen carefully to you Poor

Willingness to listen carefully to you Terrible

Willingness to listen carefully to you N/A

Taking time to answer your questions

Taking time to answer your questions Excellent

Taking time to answer your questions Very Good

Taking time to answer your questions Fair

Taking time to answer your questions Poor

Taking time to answer your questions Terrible

Taking time to answer your questions N/A

Involved you in the treatment planning (such as setting goals and frequency of appointments)

Involved you in the treatment planning (such as setting goals and frequency of appointments) Excellent

Involved you in the treatment planning (such as setting goals and frequency of appointments) Very Good

Involved you in the treatment planning (such as setting goals and frequency of appointments) Fair

Involved you in the treatment planning (such as setting goals and frequency of appointments) Poor

Involved you in the treatment planning (such as setting goals and frequency of appointments) Terrible

Involved you in the treatment planning (such as setting goals and frequency of appointments) N/A

Helped you achieve the purpose for which you sought services

Helped you achieve the purpose for which you sought services Excellent

Helped you achieve the purpose for which you sought services Very Good

Helped you achieve the purpose for which you sought services Fair

Helped you achieve the purpose for which you sought services Poor

Helped you achieve the purpose for which you sought services Terrible

Helped you achieve the purpose for which you sought services N/A

Taught skills that will help you handle future problems

Taught skills that will help you handle future problems Excellent

Taught skills that will help you handle future problems Very Good

Taught skills that will help you handle future problems Fair

Taught skills that will help you handle future problems Poor

Taught skills that will help you handle future problems Terrible

Taught skills that will help you handle future problems N/A

Provided an opportunity to make lasting meaningful change

Provided an opportunity to make lasting meaningful change Excellent

Provided an opportunity to make lasting meaningful change Very Good

Provided an opportunity to make lasting meaningful change Fair

Provided an opportunity to make lasting meaningful change Poor

Provided an opportunity to make lasting meaningful change Terrible

Provided an opportunity to make lasting meaningful change N/A

	Excellent	Very Good	Fair	Poor	Terrible	N/A
Hours of operation convenient for you	Hours of operation convenient for you Excellent	Hours of operation convenient for you Very Good	Hours of operation convenient for you Fair	Hours of operation convenient for you Poor	Hours of operation convenient for you Terrible	Hours of operation convenient for you N/A
Adequate parking	Adequate parking Excellent	Adequate parking Very Good	Adequate parking Fair	Adequate parking Poor	Adequate parking Terrible	Adequate parking N/A
Signage and directions easy to follow	Signage and directions easy to follow Excellent	Signage and directions easy to follow Very Good	Signage and directions easy to follow Fair	Signage and directions easy to follow Poor	Signage and directions easy to follow Terrible	Signage and directions easy to follow N/A
Office was clean, comfortable, and inviting	Office was clean, comfortable, and inviting Excellent	Office was clean, comfortable, and inviting Very Good	Office was clean, comfortable, and inviting Fair	Office was clean, comfortable, and inviting Poor	Office was clean, comfortable, and inviting Terrible	Office was clean, comfortable, and inviting N/A
Overall satisfaction with care from provider and staff	Overall satisfaction with care from provider and staff Excellent	Overall satisfaction with care from provider and staff Very Good	Overall satisfaction with care from provider and staff Fair	Overall satisfaction with care from provider and staff Poor	Overall satisfaction with care from provider and staff Terrible	Overall satisfaction with care from provider and staff N/A

Excellent

Very Good

Fair

Poor

Terrible

N/A

Hours of operation convenient for you

Hours of operation convenient for you Excellent

Hours of operation convenient for you Very Good

Hours of operation convenient for you Fair

Hours of operation convenient for you Poor

Hours of operation convenient for you Terrible

Hours of operation convenient for you N/A

Adequate parking

Adequate parking Excellent

Adequate parking Very Good

Adequate parking Fair

Adequate parking Poor

Adequate parking Terrible

Adequate parking N/A

Signage and directions easy to follow

Signage and directions easy to follow Excellent

Signage and directions easy to follow Very Good

Signage and directions easy to follow Fair

Signage and directions easy to follow Poor

Signage and directions easy to follow Terrible

Signage and directions easy to follow N/A

Office was clean, comfortable, and inviting

Office was clean, comfortable, and inviting Excellent

Office was clean, comfortable, and inviting Very Good

Office was clean, comfortable, and inviting Fair

Office was clean, comfortable, and inviting Poor

Office was clean, comfortable, and inviting Terrible

Office was clean, comfortable, and inviting N/A

Overall satisfaction with care from provider and staff

Overall satisfaction with care from provider and staff Excellent

Overall satisfaction with care from provider and staff Very Good

Overall satisfaction with care from provider and staff Fair

Overall satisfaction with care from provider and staff Poor

Overall satisfaction with care from provider and staff Terrible

Overall satisfaction with care from provider and staff N/A

Satisfaction Survey

We want to hear from you!

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* 1. Please indicate the type of services you received:

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* 2. Are you a new or returning client?

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* 3. Client:

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* 4. Provider:

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* 5. Your Appointment:

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* 6. Our Staff:

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* 7. Your Visit With The Provider:

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* 8. Our Facility:

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* 9. Would you recommend our practice to others?

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* 10. If there is any way we can improve our services to you, please tell us about it: