Speech, Language & Learning Center of TN, L.L.C Patient Survey

Thank you for trusting us to provide services to your child. We ask for your help and feel assured that your suggestions for this practice will allow us to improve future services to all patients. All information will be confidential to the owner, Becky Brown & Kylie Mansfield. Your name is optional.

Name: (optional)

First NameLast Name

Who referred you to us?

In which office were you seen?

ColumbiaLawrenceburg

What services did you receive here?

Speech TherapyOccupational Therapy

What was your method of payment?

Private PayTennCareCommercial Insurance

On, or before your first visit, did a staff member review:

	Yes	No
Your expected payment?
Review attendance Polices?
Were you satisfied with billing services and payment plans?
Were you contacted by your child's evaluating therapist prior to your first visit:
Did you feel that your billing and health information was held confidential?

This information will be strictly confidential to Becky Brown & Kylie Mansfield and will only be used for the purpose of improving our services to our patients. Please be honest and offer comments.

Who is your child's therapist?

Please rate the following with 5 being the BEST and 1 being the LOWEST score.

	5	4	3	2	1
Meet you on time for sessions?
Provide you with specific goals and plans for treatment?
Discuss your child's progress toward meeting those goals with you on a regular basis?
Listen to your concerns?
Interact well with your child?
Motivate your child to work hard and achieve goals?
Provide written reports to you and the doctor?
Make and keep appointments in a professional relationship with you?
Return phone calls in a timely manner?
Maintain a strictly professional relationship with you?
Maintain complete privacy regarding your child?
Maintain a room free of clutter and distractions?
Overall, how pleased are you with your child's therapist?

Please offer any comments about your child's therapist, or the Center, that would help us provide better services:

Are you friends with us on:

	Yes	No
Facebook?
Instagram?