• CONSENT TO BE CONTACTED FOR POST-VISIT SATISFACTION SURVEY FORM

  • Northlight Counseling Associates is committed to ensuring patients' satisfaction of services received. Center has contracted with a third party - Burke, Inc. - to conduct satisfaction surveys on our behalf. The survey will be provided online and will take no more than IO minutes to complete. If you agree to be contacted to participate in a survey about our services, please indicate your consent by checking one of the boxes below:

  • I confirm that I have read and fully understand the above information prior to my signing and all of my questions regarding this form have been answered to my satisfaction. I agree that I am signing this Consent to be Contacted for Post-Visit Satisfaction Survey Form freely and voluntarily. I understand that my consent given with my signature below will remain in effect unless and until I cancel such consent in writing pursuant to the terms set forth above.

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