Client Self-Evaluation and Treatment Feedback Questionnaire Form
Please share your honest feedback about your experience and treatment. Your responses help us improve our services.
Overall, how satisfied are you with your experience?
*
1
2
3
4
5
How well did your treatment meet your needs?
*
Not at all
1
2
3
4
Completely
5
1 is Not at all, 5 is Completely
How likely are you to recommend our services to others?
*
Not likely
1
2
3
4
Extremely likely
5
1 is Not likely, 5 is Extremely likely
The staff treated me with respect and courtesy.
*
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
My concerns and questions were addressed during treatment.
*
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
How comfortable did you feel during your treatment sessions?
*
Very uncomfortable
1
2
3
4
Very comfortable
5
1 is Very uncomfortable, 5 is Very comfortable
The treatment plan was clearly explained to me.
*
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
What aspect of your experience was most helpful?
What could we improve to enhance your experience?
Any additional comments or suggestions?
Submit Feedback
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