Client Feedback Survey

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 is reviewed by our Leadership Team: Chief Executive Officer (Ann Poortinga), Chief Clinical Director (Renee Pinkelman), and Administrative Manager (Emily Schmidt). If you feel more comfortable contacting someone directly instead of completing this survey, please email our Administrative Manager: emily@layandassociates.com or call (937) 767-9171 ext. 101.
Your Name

First NameLast Name
Client's Name (if you are completing this on someone else's behalf)

First NameLast Name
Your relationship to the client (if you are completing this on someone else's behalf)
Email*
example@example.com
Who is/was the provider you worked with? *
Name of the provider you saw
Was this provider a good match for you?*

YESNO
May we contact you to offer a therapist in our practice or another practice that may better suit your needs?*

YESNO
Do you receive virtual services, in-person services, or a hybrid of both?

VirtualIn-PersonHybrid (both virtual and in-person)
Tell us more about your therapy/counseling experience
Your provider's ability to understand your needs

Very GoodGoodOkayPoorVery Poor
I felt heard by my provider

Not at allSomewhatCompletely
Usefulness of therapy in meeting your needs and goals

Very usefulMostly usefulNeutralNot really usefulNot at all useful
I was provided with information, therapist support, and strategies for emotional health that matched my needs

Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
Overall, how satisfied are you with the care you received from this provider?

Very satisfiedSomewhat satisfiedNeutralSomewhat unsatisfiedVery 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?

ExcellentPretty goodOkaySomewhat poorPoor
Overall, how do you feel your experience has been with our office staff?

Very goodPretty goodOkaySomewhat poorVery poor
Overall, do you feel better after coming here?

Significant improvementSome improvementNeutralNo improvementI feel worse
Would you recommend our services to family/friends?

YesProbablyUnsureProbably notDefinitely 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?

YesNot at this time
What phone number should we call to contact you about your experience?
Should be Empty:

Client Feedback Survey

Tell us more about your therapy/counseling experience

Tell us more about your overall experience with our office