Tell Us How We're Doing!

Tell Us How We're Doing!

Please take a few moments to complete this form. It should only take 5 minutes!
What is your relationship with us?

Current ClientProspective ClientFamily Member of ClientStaffProfessional ReferralOther
What Service(s) have you received?

Assessment OnlyIndividual TherapyCouple TherapyGroup TherapyMedication Management
How many visits Have you had?

1-3 Visits3-7 Visits7-12 VisitsMore than 12 VisitsOther
Please rate your overall experience
Uh Oh! We're sad to hear you had an unpleasant experience.This survey is annonymous, but if you would like a member of our leadership team to contact you about your experience, please email feedback@waccenter.com
Do you want to shout out your provider? Use this section to compliment or brag about your provider. Since this form is anonymous, we will pass along the compliment.

Overall satisfaction

	Very satisfied	Satisfied	Neutral	Unsatisfied	Very unsatisfied
Front Office Telephone Etiquette and Customer Service
Appointment Scheduling and Convenience
Payment and Billing
Quality of Clinical Services
Technology and Telehealth Services
Professionalism of Clinical Staff

Tell us about your experience? What do you like? How can we improve our service?
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