Patient Satisfaction Survey



We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential and anonymous. Thank you for your time.



Patient`s Age
Patient's Sex:    Male
   Female
In which clinic did you primarily receive services?
Which therapies were received? Please check all that apply.

Physical Therapy
Occupational Therapy
Speech Therapy
Ease of getting care:
Ability to get in to be seen:
Hours Clinic is open:
Convenience of Clinic's location:
Prompt return on calls:

Waiting:
Time in waIting room:

Clinical Staff:
Therapist/Staff listens to you:
Provides a warm, friendly experience:
Answers your questions effectively:
Gives you good advice and treatment:

Administration:
Friendly and helpful to you:
Answers your questions:
Explanation of charges:
Collection of payment/money

Facility:
Neat and clean building:
Ease of finding where to go:
Comfort and safety while waiting


How did you hear about us?
Would you refer your friends and relatives to us?    Yes
   No
   Maybe
What did you enjoy most about our clinic?
What did you like least about our clinic?
Do you have any suggestions for improvement?
If you feel comfortable in saying, who was your treating therapist?
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