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Please respond to the following questions using the drop down menus. 
 

How did you hear about Charles?
How pleasant was the waiting room area
How pleasant was the office setting
How well did the office staff do their job
Was the fee fair and reasonable
Was Charles’ behavior appropriate
How well did Charles know what he was doing
How confident are you that Charles will be able to help you
How well did the therapy experience met your needs
How confident are you about recommending Charles to a friend or relative
How likely is it that you will continue to meet with Charles on a regular basis
How likely is it that you will meet with Charles on an as needed basis
How sure are you that you would return to Charles in the future if you need additional therapy services
I would like Charles contact me through email for follow-up purposes in the future. (if yes, submit email address below in comments box) 
Suggestions for Charles / Additional comments:
 

Thank you for participating!