Client Feedback Survey
We take feedback from our clients very seriously and always appreciate knowing more about your experience with our office. Please take a moment to let us know how we are doing. This feedback goes to our Clinical Director and our Director of Operations. If you feel more comfortable contacting them directly instead of completing this survey, please email our Director of Operations, Ann Poortinga, at admin@layandassociates.com or leave a message at (937) 767-9171 for our Clinical Director, Renee Pinkelman.
Name
First Name
Last Name
Email
*
example@example.com
Who is/was the provider you worked with?
*
Please Select
Tim Callahan, PsyD
Jack Campbell, LICDC
Lia Ferrell, LISW
William Ford, MRC
Joyce Girard, LSW, LICDC
Elizabeth Goodall, LPCC
Mark Greenberg, LISW-S
Megan Harcourt, LISW-S
Stanford Harris, LICDC
John "Jack" Layh, PhD
Marlee Layh, PhD
Melissa Layman-Guadalupe, PhD
Kate LeVesconte, PsyD
Renee Pinkelman, LPCC
Marcie Rogers, PhD
Tracy Sebastian, LISW-S
Justin Simons, LPCC
Judy Skillings, PsyD
Louise Smith, LPCC
I have not seen anyone yet
Was this provider a good match for you?
*
YES
NO
May we contact you to offer a therapist in our practice or another practice that may better suit your needs?
*
YES
NO
Do you receive virtual services, in-person services, or a hybrid of both?
Virtual
In-Person
Hybrid (both virtual and in-person)
Tell us more about your therapy/counseling experience
Your provider's ability to understand your needs
Very Good
Good
Okay
Poor
Very Poor
I felt heard by my provider
Not at all
Somewhat
Completely
Usefulness of therapy in meeting your needs and goals
Very useful
Mostly useful
Neutral
Not really useful
Not at all useful
I was provided with information, therapist support, and strategies for emotional health that matched my needs
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Overall, how satisfied are you with the care you received from this provider?
Very satisfied
Somewhat satisfied
Neutral
Somewhat unsatisfied
Very unsatisfied
Is there anything specific that you would like to share with us about your experience with this provider?
Tell us more about your overall experience with our office
How would you rate your communication with our office staff?
Excellent
Pretty good
Okay
Somewhat poor
Poor
Overall, how do you feel your experience has been with our office staff?
Very good
Pretty good
Okay
Somewhat poor
Very poor
Overall, do you feel better after coming here?
Significant improvement
Some improvement
Neutral
No improvement
I feel worse
Would you recommend our services to family/friends?
Yes!!
Probably
Unsure
Probably not
Definitely not
Is there anything specific that you would like to share with us about your experience with our office or the therapist you saw?
Would you like someone from our office to contact you about your experience?
Yes
Not at this time
What phone number should we call to contact you about your experience?
Submit
Should be Empty: