PATIENT SURVEY Patient Satisfaction Survey Survey Date Please print the First name of your therapist: Why did you choose this office/therapist? InternetFriend/FamilyLocation/HoursPhysician referredInsuranceOther 1) My therapist was courteous No OpinionStrongly DisagreeDisagreeAgreeStrongly Agree 2) My therapist understood my problem or condition No OpinionStrongly DisagreeDisagreeAgreeStrongly Agree 3) The explanations my therapist gave me were helpful No OpinionStrongly DisagreeDisagreeAgreeStrongly Agree 4) The front desk person was courteous No OpinionStrongly DisagreeDisagreeAgreeStrongly Agree 5) I was satisfied with the treatment provided by the therapist No OpinionStrongly DisagreeDisagreeAgreeStrongly Agree 6) I was satisfied with the treatment provided by the aides No OpinionStrongly DisagreeDisagreeAgreeStrongly Agree 7) Facility scheduled appointments at convenient times No OpinionStrongly DisagreeDisagreeAgreeStrongly Agree 8) My first visit was scheduled quickly No OpinionStrongly DisagreeDisagreeAgreeStrongly Agree 9) It was easy to scheduled follow-up appointments No OpinionStrongly DisagreeDisagreeAgreeStrongly Agree 10) I was seen promptly when I arrived for treatment No OpinionStrongly DisagreeDisagreeAgreeStrongly Agree 11) The location of the facility was convenient for me No OpinionStrongly DisagreeDisagreeAgreeStrongly Agree 12) Parking was available for me No OpinionStrongly DisagreeDisagreeAgreeStrongly Agree 13) My bills were accurate No OpinionStrongly DisagreeDisagreeAgreeStrongly Agree 14) The cost of treatments I received were reasonable No OpinionStrongly DisagreeDisagreeAgreeStrongly Agree 15) I was satisfied with the overall quality of care No OpinionStrongly DisagreeDisagreeAgreeStrongly Agree 16) I would recommend this facility to family or friends No OpinionStrongly DisagreeDisagreeAgreeStrongly Agree 17) I would return to this facility for care in the future No OpinionStrongly DisagreeDisagreeAgreeStrongly Agree 18) My privacy was respected during my care No OpinionStrongly DisagreeDisagreeAgreeStrongly Agree 19) Overall, I was satisfied with my experience here No OpinionStrongly DisagreeDisagreeAgreeStrongly Agree 20) Your Age 21) Your Gender MaleFemale 22) Was this your first experience with this therapist or facility YesNo 23) Was this your first experience with this type of care? YesNo 24) What did you like BEST about your experience? 25) What did you like LEAST about your experience? 26) What would you say to someone considering this therapist or facility? 27) On a Scale of 1-5 Star rating, how would you rate this facility? May we use your statement in our marketing materials? YesNo May we use your first name? YesNo May we post your statement on our website and social media? YesNo (if you answered Yes to the questions above, please complete the rest of this form) Full Name Signature Date
