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 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? *
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?
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Client Feedback Survey

Tell us more about your therapy/counseling experience

Tell us more about your overall experience with our office