* = Required Information
Compassion
Listens to you:
Great
Good
OK
Fair
Poor
Takes enough time with you:
Great
Good
OK
Fair
Poor
Explains what you want to know:
Great
Good
OK
Fair
Poor
Friendly and helpful to you:
Great
Good
OK
Fair
Poor
Answers your questions:
Great
Good
OK
Fair
Poor
Staff
Comfort and safety with your clinician:
Great
Good
OK
Fair
Poor
Prompt return on calls:
Great
Good
OK
Fair
Poor
Satisfied with appointments and scheduling:
Great
Good
OK
Fair
Poor
My caregiver was professional and courteous:
Great
Good
OK
Fair
Poor
Treatment and Outcomes
I received good advice and treatment:
Great
Good
OK
Fair
Poor
I understood the explanation of what was being done during my treatment sessions:
Great
Good
OK
Fair
Poor
I understood the instructions and demonstration of my home program:
Great
Good
OK
Fair
Poor
I was satisfied with the amount of input I had in seeking the goals for my treatment:
Great
Good
OK
Fair
Poor
I was satisfied with the improvements I made because of the treatment I received:
Great
Good
OK
Fair
Poor
Confidentiality
Keeping my personal information private:
Great
Good
OK
Fair
Poor
Overall Satisfaction
My overall satisfaction with the services provided:
Great
Good
OK
Fair
Poor
Comments or suggestions for improvement:
(Optional)
Your Name:
Caregivers Name:
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