Satisfaction Survey

We take your experience & opinions seriously.
Please tell us about the care you’ve received through PHA Wellness.
You may answer the questionnaire anonymously if you wish.

Tell Us How We’re Doing

"*" indicates required fields

Date

1.) What type/s of service/s did you receive at our clinic? (check all that apply)*

Individual Counseling/Psychotherapy

Couples or Family Counseling/Psychotherapy

Group Therapy

Psychiatry/Medication Management

2) Which provider or providers did you see?*

If you saw more than one provider at our clinic, we would appreciate your feedback on those services as well.

Quality of Service You Received:

(1-disagree, 2- somewhat disagree, 3 -neutral, 4-mostly agree, 5- strongly agree)

3.) Provider seemed knowledgable regarding your problem/s.*

Please enter a number from 1 to 5.

4.) You felt generally heard and understood by your provider.*

Please enter a number from 1 to 5.

5.) Provider provided adequate empathy and emotional warmth?*

Please enter a number from 1 to 5.

6.) Provider offered helpful information, advice, &/or insight?*

Please enter a number from 1 to 5.

7.) The services you received were helpful. Did you get better, &/or resolve the problems/issues that brought you?*

Please enter a number from 1 to 5.

8.) Would you reccommend your therapist or provider to others?*

Ease, Convenience, Efficiency, Comfort

(1-very dissatisfied, 2-somewhat dissatisfied, 3-neutral, 4-somewhat satisfied, 5-very satisfied)

9.) Your overall satisfaction with our intake procedures (initial contact & scheduling with our admin staff, insurance checking, patient portal, intake forms, etc.*

Please enter a number from 1 to 5.

10.) Your overall experience scheduling appointments with your provider/s.*

Please enter a number from 1 to 5.

11.) Your overall experience with our billing system and procedures.*

Please enter a number from 1 to 5.

12.) Your overall satisfaction with our office building, consulting rooms, waiting area, telehealth platform, and/or parking availability.*

Please enter a number from 1 to 5.

14.) Would you recommend this clinic to others?*

Yes

No

Not sure

15.) Your experience matters to us! We welcome all feedback, suggestions, & complaints? Please give specifics:

17.) Do you give us permission to use your comments as testimonial quotes, with your first name & last initial (e.g., Sarah R)?*

If yes: Please enter the first name and last initial, or alias you would like us to use (e.g., Sarah R.):

16.) May we contact you directly regarding your experience at our clinic?*

Name (optional)

First Last

Phone number

Email

Thank You!

We appreciate your feedback so that we may improve the services we provide.

Phone

This field is for validation purposes and should be left unchanged.