New Patient Satisfaction Survey

To help us improve the quality of care and the administrative services we provide, would you please answer the following 8 questions and submit for our review? Thank you in advance and if there are any issues of concern that you would like to speak to someone about, please indicate this at the bottom so we might contact you either by phone or email (your choice).

Thank you for your time and feedback,

Evan Greenwald, Ph.D.
Director

How helpful was the intake specialist who first scheduled your first appointment?

Overall, how easy or simplified was the process of obtaining your first appointment with us?

How convenient/easy was it to complete paperwork for your first time appointment upon arrival or via the internet?

Did you complete your paperwork upon arrival or via internet?

Arrival

Internet

How helpful were we in providing you in advance or at your first appointment information regarding the costs of service and your insurance coverage for those services?

How helpful was the email info sent to you confirming your appointment and orienting you to the services you would receive?

How easily were you able to find our office given the directions you obtained from us?

If you had difficulty locating us, what could we do to improve that process?

0/300 characters

Which office did you visit for your first appointment?

How professional in appearance was the interior of your provider's office?

How professional or appealing in appearance and upkeep were the general waiting rooms and the decor of the waiting and common areas?

How satisfied were you and how much confidence do you have that the provider you were matched with will be of help to you going forward and was a good "match"?

If you saw a second provider, how satisfied were you and how much confidence do you have that the second provider you were matched with will be of help to you going forward and was a good "match"?

Provider #1:

Provider #2 (if more than one provider was seen):

Can you provide specific feedback to help us improve our services or facilities by making any recommendations for us?

0/300 characters

Do you have any particularly positive feedback to pass on to others about any aspect of your experience obtaining and attending your first appointment?

0/300 characters

You may share my feedback anonymously on The Counseling Center website. *

Yes

No

You may share my feedback anonymously online via Google, Yelp or Health Grades *

Yes

No

If we would like to contact you to discuss anything we did particularly well, anything that needs serious improvement so we might obtain further feedback, or if you would like us to contact you to remedy any concerns with your care or your experience, would you be willing to provide your confidential contact information?

Name:

Phone:

Email:

(Although this survey form is HIPAA compliant and secure, emails sent to you in follow up may not be. If there is anything of concern you would like to discuss, but would prefer a confidential phone call, you may leave the email field blank and we will only call you. If you don't mind the fact that email is not a HIPAA compliant secure way to communicate, and if you would like us to communicate or reply to you via email, please fill in the email address above, or complete both phone and email fields so we may contact you either way. Thank you.)

No Answer	Very Unhelpful	Somewhat Unhelpful	Reasonably Helpful	Very Helpful
Extremely Helpful

Nashua	Raymond	Milford	Derry
Exeter	Manchester	Peterborough	Londonderry
Portsmouth	Center Harbor	Portland, ME	Brunswick, ME