When you take our survey, you'll be automatically entered in to a monthly drawing for $25! Rest assured, any comments you leave here will remain anonymous and will not be shared with anyone outside the company.
Name Gender Female Male Age 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 Date of Visit Therapist Choose One Jodi K. Bright Christine Brudnicki Patricia Connelly Lori Eklund Walsh Karen Garnett Robert J. Gillette Russell D. Girard Dennice Y. Janz Maureen Jensen Johanna John Madeline Kelley Jean Neira Sue Nelms Mary Sokup Edwin (Ed) Steinacker Dana Stewart Cory Tischman Please answer the following questions using this scale: 1 - Not at all 2 - Somewhat 3 - Yes 4 - Very much Was today's session helpful? 1 2 3 4 Are you resolving your problem? 1 2 3 4 Are you and your therapist a good fit? 1 2 3 4 Did the office staff treat you with respect? 1 2 3 4 Are you seen often enough? 1 2 3 4 Comments Confirm Code
Name
Gender Female Male
Age 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99
Date of Visit
Therapist Choose One Jodi K. Bright Christine Brudnicki Patricia Connelly Lori Eklund Walsh Karen Garnett Robert J. Gillette Russell D. Girard Dennice Y. Janz Maureen Jensen Johanna John Madeline Kelley Jean Neira Sue Nelms Mary Sokup Edwin (Ed) Steinacker Dana Stewart Cory Tischman
Please answer the following questions using this scale: 1 - Not at all 2 - Somewhat 3 - Yes 4 - Very much
Was today's session helpful?
1
2
3
4
Are you resolving your problem?
Are you and your therapist a good fit?
Did the office staff treat you with respect?
Are you seen often enough?
Comments
Confirm Code