Referral Satisfaction Survey Question Title * 1. What county do you generally work from? Pulaski County Miami County Cass County Fulton County Howard County Other (please specify) Question Title * 2. Which of the following best describes your current occupation? Teacher School Social Worker/Counselor Probation Physician Healthcare Support Occupations School Administration Other Healthcare Occupation Family Member Department of Child Services (DCS) Friend Other (please specify) Question Title * 3. How did you hear about Four County? Billboard Commercial From a Friend Social Media Other (please specify) Question Title * 4. Overall, I am satisfied with the service Four County provides to my clients. Strongly Agree Agree Disagree Strongly Disagree Question Title * 5. Written and/or verbal clinical communications from our clinicians are informative and helpful. Strongly Agree Agree Disagree Strongly Disagree Question Title * 6. Staff are helpful and professional. Strongly Agree Agree Disagree Strongly Disagree Question Title * 7. The referral process is easy to understand and hassle free. Strongly Agree Agree Disagree Strongly Disagree Question Title * 8. When I call the office, the phone is answered promptly. Strongly Agree Agree Disagree Strongly Disagree Question Title * 9. I am satisfied with how quickly the person(s) I refer are able to start services. Strongly Agree Agree Disagree Strongly Disagree Question Title * 10. I will continue to refer people to Four County. Strongly Agree Agree Disagree Strongly Disagree Question Title * 11. People I have referred have received high quality treatment. Strongly Agree Agree Disagree Strongly Disagree Question Title * 12. What other facilities do you refer people to for mental health services? Question Title * 13. How would you rate your overall satisfaction with our agency? Not satisfied at all - 0 1 2 3 4 5 6 7 8 9 Extremely satisfied - 10 Not satisfied at all - 0 1 2 3 4 5 6 7 8 9 Extremely satisfied - 10 Question Title * 14. Please give us any suggestions that you can think of to improve your experience as a referral source to Four County. Question Title * 15. Please leave us your email address so that we can add you to our monthly newsletter. Submit response