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Client Survey

Page One

2. At what location did you see this provider?
3. Please rate your provider in the following areas.
Space Cell Poor
0
1234Excellent
5
Overall rating
Courtesy and professionalism
Understanding of your issue/situation
Effectiveness in treating your issue/situation
What are the chances you would refer a friend or family member to this provider?
4. Did you schedule a follow up appointment? If no, why not?
6. Please rate the following regarding the clinic.
Space Cell Poor
0
1234Excellent
5
Ease of scheduling of your initial appointment
Atmosphere of the office (if applicable)
The receptionist on staff (if applicable)
8. Please rate the following if you had a telemedicine visit: 
Space Cell Poor
0
1234Excellent
5
Ease of connecting to visit
Quality of video connection
Quality of audio connection

This information will remain confidential and anonymous.

If you would like to contact us regarding this survey or provide additional feedback, please contact Molly Kehr, MA, LMFT, Director of Business Development directly at 651-286-8591.