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Surveys & Forms

Survey for Outpatient Therapy

Our goal is to provide you with a "Remarkable" patient care experience. With your input we hope to achieve this goal. If you would like us to contact you regarding your comments, please include your name and telephone number.

* Indicates required information
1. *
Please indicate the location where you were seen.
2. *
Please indicate the rehabilitation services you received.
3. *
Would you like to be contacted to talk about your experience further?
      
4.
If yes, please indicate how we can contact you.
5. *
Did you feel that our Receptionist showed compassion for you during your therapy sessions?
        
6. *
Did you feel that our Aides showed compassion for you during your therapy sessions?
        
7. *
Did you feel that our Therapists showed compassion for you during your therapy sessions?
        
8. *
Did our Receptionist show concern for your privacy and dignity?
        
9. *
Did our Aides show their concern for your privacy and dignity?
        
10. *
Did our Therapists show their concern for your privacy and dignity?
        
11. *
Was our Receptionist cheerful and courteous?
        
12. *
Were our Therapists cheerful and courteous?
        
13. *
Would you return to our clinic again, if you needed rehabilitation services?
        
14. *
Would you recommend us to others?
        
15.
Was there anything that was frustrating or disappointing in your therapy experience? What more could have been done for you?
16.
Did we do anything for you that was memorable? Is there anyone you would like to recognize?
17.
Additional Comments
Authentication *
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