Mental Health Client Discharge Feedback Form
Please provide your feedback on your recent experience with our mental health services after discharge. Your input helps us improve our care.
Client Full Name
*
First Name
Last Name
Date of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Mental Health Services Received
*
Please Select
Individual Therapy
Group Therapy
Medication Management
Crisis Intervention
Other
How satisfied were you with the overall quality of care you received?
*
1
2
3
4
5
Please rate the following aspects of your care:
*
Rows
Helpfulness of Staff
Communication with Providers
Support for Your Needs
Discharge Planning Process
Very Unsatisfied
1
2
3
4
Unsatisfied
5
6
7
8
Neutral
9
10
11
12
Satisfied
13
14
15
16
Very Satisfied
17
18
19
20
Did you feel prepared to manage your mental health after discharge?
*
Yes
Somewhat
No
What aspects of your care were most helpful?
What could we have done to improve your experience?
Would you recommend our mental health services to others?
*
Yes
No
Not Sure
May we contact you for follow-up about your feedback?
*
Yes, you may contact me.
No, please do not contact me.
If yes, please provide your preferred contact email.
example@example.com
Submit Feedback
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