Client Satisfaction Survey

In an effort to continually improve our services we would greatly appreciate your time in
completing this questionnaire.  You are not required to disclose any identifying information.  This
is purely for our improvement.
     
Please circle the name of your therapist and your responses below:

  Gretchen Laporta LCSW                Lee Hasty LCSW

Today’s Date:  ____________  Estimated treatment length: ___________


1.        Overall, how satisfied are you with the therapeutic services you have received?

Very Satisfied    Satisfied   Undecided  Dissatisfied  Very Dissatisfied   Not Applicable

2.        Considering all of the expectations you may have had about the services, to what extent
have the services met your expectations?

Very Satisfied    Satisfied   Undecided  Dissatisfied Very Dissatisfied   Not Applicable

3.        How satisfied are you with your therapist’s level of knowledge and professionalism?

Very Satisfied    Satisfied   Undecided  Dissatisfied  Very Dissatisfied   Not Applicable

4.        How satisfied are you with your therapist in responding to emergencies and returning
phone calls?

Very Satisfied    Satisfied   Undecided  Dissatisfied  Very Dissatisfied   Not Applicable

5.        How satisfied are you with your therapist being on time for appointments?

Very Satisfied    Satisfied   Undecided  Dissatisfied  Very Dissatisfied   Not Applicable

6.       How satisfied are you that you have met your goals/purpose for coming?

Very Satisfied    Satisfied   Undecided  Dissatisfied  Very Dissatisfied   Not Applicable

7.        Should the need arise would you utilize this therapist again?
                     __Yes                __ No

8.        Would you recommend this therapist to a friend or family member?
                     __ Yes        __ No

9.        How satisfied are you with the environment of the office?

Very Satisfied    Satisfied   Undecided  Dissatisfied  Very Dissatisfied   Not Applicable

Please use this space to let us know how we can improve our services, office/billing procedures
or office environment.









What would did you like about us that we should continue.








You may return the survey via mail to:
2649 Brekonridge Centre Dr.  Suite 112 Monroe NC 28110

Thank you for your time and helping us improve!