EmailMe Form - Therapy Feedback Form

1. Please select the category that shows how you were referred to Bayview Therapeutic Services *

2. How many sessions did you attend? *

1-3

4-10

Over 10

3. What kind of therapy did you receive? *

Individual

Couple

Family

Child/Adolescent

4. Did the office atmosphere help you to feel more comfortable? *

Yes

No

7. Overall, how would you rate your experience? *

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
I felt heard, understood, and respected by Dr. Kate.	1	2	3	4	5
Dr. Kate was qualified to work with me.	1	2	3	4	5
Dr. Kate's approach was a good fit for me.	1	2	3	4	5
I would recommend Dr. Kate to a friend/family member.	1	2	3	4	5

6. If you were satisfied with the therapy services you received from Dr. Kate, please describe your experience in a testimonial. *

5. What did you find the most helpful about your therapy with Dr. Kate? *

5. Do you have any feedback on how Dr. Kate could improve her services? *

3. Can Dr. Kate publish your testimonial on her website or advertising products? *

Yes

No

5. If yes, how would you like to be identified on the testimonial page? (Leave blank if you prefer to remain anonymous) *

8. What is your email address?