Hotline Caller Discharge Feedback Form
Please provide your feedback regarding your recent experience with our hotline service. Your responses will help us improve our support.
Full Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Hotline Call
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
What was the primary reason for your call?
*
Please Select
Emotional support
Information request
Crisis intervention
Referral to services
Other
How did you hear about our hotline?
Please Select
Friend or family
Healthcare provider
Internet search
Social media
Other
Please rate the following aspects of your hotline experience:
*
Rows
Friendliness of staff
Helpfulness of information
Wait time to connect
Overall satisfaction
Very dissatisfied
1
2
3
4
Dissatisfied
5
6
7
8
Neutral
9
10
11
12
Satisfied
13
14
15
16
Very satisfied
17
18
19
20
Did the hotline staff address your needs or concerns?
*
Yes, completely
Partially
No
How likely are you to recommend our hotline to others?
*
Not likely
1
2
3
4
5
6
7
8
9
Extremely likely
10
1 is Not likely, 10 is Extremely likely
What did you find most helpful about your experience?
What could we do to improve our hotline service?
Additional comments or suggestions
Submit Feedback
Should be Empty: