Patient Satisfaction Survey

Thinking about your last visit, please indicate the type of practitioner you saw: *

Visits with your Practitioner

Think about practitioner whom you saw your last visit, how would you rate him/her:

Continuing to think about the visit you had with the practitioner on the date identified in the letter, please rate your agreement with the following statements:

11. How likely would you be to recommend this practitioner to a friend or family member? *

Scheduling an Appointment

Your first call to DCBHS (before you had been matched with a practitioner) was with staff member employed by DCBHS. Thinking back to that phone call you made to DCBHS to get to an appointment, please rate your agreement with the following statements:

Behavioral Health Services in General

Thinking about the counseling or treatment you may have received through DCBHS over the last 12 months (this would include care received at the practitioner’s office listed in the letter), please respond to the following questions:

17. The information I received (materials, what staff/practitioners told me, etc.) was consistent: *

18. All things considered, how satisfied are you with DCBHS for counseling or treatment? *

If you would like to make comments about your care, or have suggestions for how we can improve our service, please use the space provided in the space below:

Can we use your comment as a published testimonial? *

Yes, use my intials (please provide at end of comments section) Yes, but remain anonymous I do not wish for my comment to be published.