Providing a Safe Place to Explore Your Thoughts & Feelings.

Get Directions To Our Office
Make An Appointment Today 860.647.8995

Patient Satisfaction Survey

Click here to download the form.

Dear client:

In order to evaluate our effectiveness and improve our clinical skills, it would help us a great deal if
you would complete this questionnaire. Your feedback is valuable to us. Please do not sign your name. This way you can feel free to be completely honest.

Therapist/Doctors Name:

Please rate the following:

1 = Excellent      2 = Very Good      3 = Good      4 = Fair      5 = Poor

1. During the 3 weeks prior to beginning treatment here, how would you rate the state of your overall mental health?
2. During the 3 weeks prior to beginning treatment here, how would you rate the state of the specific mental health issue that brought you here?
3. During the 5 weeks after your treatment here, how would you rate the state of your overall mental health?
4. During the 5 weeks after your treatment here, how would you rate the state of the specific mental health issue that brought you here?
5. At termination of your treatment here, how would you rate the state of your overall mental health? (If applicable)
6. At termination of your treatment here, how would you rate the state of the specific mental health issue that brought you here? (If applicable)
7. How long has it been since the termination of your treatment here?
8. How would you rate the state of your overall mental health now?
9. How would you rate the specific mental health issue that brought you here?
10. Rate your ability to sustain any positive strides you made here.
11. Rate the helpfulness of this therapist.
12. Please list on the back side, any specific strengths and/or weaknesses of this provider and his/her staff.
 

 

Click here to download the form.