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SURVEY
Please respond to the following questions using the drop down menus.
How did you hear about Charles?
(select)
Insurance company
His website
A friend
Magazine article
Web search
A Colleague
How pleasant was the waiting room area
Extremely
Very
Some what
Not very
Not at all
How pleasant was the office setting
Extremely
Very
Some what
Not very
Not at all
How well did the office staff do their job
Extremely
Very
Some what
Not very
Not at all
Was the fee fair and reasonable
Extremely
Very
Some what
Not very
Not at all
Was Charles’ behavior appropriate
Extremely
Very
Some what
Not very
Not at all
How well did Charles know what he was doing
Extremely
Very
Some what
Not very
Not at all
How confident are you that Charles will be able to help you
Extremely
Very
Some what
Not very
Not at all
How well did the therapy experience met your needs
Extremely
Very
Some what
Not very
Not at all
How confident are you about recommending Charles to a friend or relative
Extremely
Very
Some what
Not very
Not at all
How likely is it that you will continue to meet with Charles on a regular basis
Extremely
Very
Some what
Not very
Not at all
How likely is it that you will meet with Charles on an as needed basis
Extremely
Very
Some what
Not very
Not at all
How sure are you that you would return to Charles in the future if you need additional therapy services
Extremely
Very
Some what
Not very
Not at all
I would like Charles contact me through email for follow-up purposes in the future. (if yes, submit email address below in comments box)
Yes
No
Suggestions for Charles / Additional comments:
Thank you for participating!