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,

The Management Team

Are you: *

Please check the box for the office you were seen in (more than one box may be checked if you were seen in multiple locations).
Please answer the following on a 5 point scale, 1 being a very dissatisfied and 5 indicating an extremely satisfied experience at The Counseling Center.

1 = very dissatisfied   2 = dissatisfied   3 = basically satisfied   4 = very satisfied   5 = extremely satisfied
1. Overall, how satisfied were you with the care delivered by your provider (#1) above?
Overall, how satisfied were you with the care delivered by your provider (#2) above (if you saw 2 providers)?
2. Overall, how satisfied were you with the administrative aspects of our practice?
3. How satisfied were you with your intake process to obtain your first appointment?
4. How satisfied were you with the front desk reception staff and your process of checking in and/or scheduling?
5. How satisfied were you with our billing and account management?
6. How satisfied were you with the ease of parking for your appointment?

0/450 characters

8.  Would you refer a friend of family member to The Counseling Center for services?
0/300 characters

0/400 characters

May we contact you?

Because we really value your feedback, sometimes we would appreciate the chance to talk with you to gather further information about any opinions you may have shared with us.  This often helps us make needed changes and improve our system. Similarly, if we can help you in any way, we would genuinely like to do so in order to improve the quality of care or any administrative aspects of our practice.

If you would allow us to reach out to you, please provide your contact information below.  If you would prefer to remain anonymous, we understand that and are grateful for the feedback you have provided so far.

You may also email us directly with any other information, or reach out for assistance, by emailing  ( (Director).

You may share my feedback anonymously on The Counseling Center website. *
You may share my feedback anonymously online via Google, Yelp or Health Grades *

(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.)
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