EmailMe Form - Therapy Feedback Form

How did you hear about us? *

If other, please specify:

How many therapy visits did you attend *

1-3

4-10

Over 10

The office environment was pleasant and comfortable. *

Agree

Neutral

Disagree

Overall, how would you rate your experience?

Evaluate the following statements. *

	Strongly Disagree	Disagree	Agree	Strongly Agree
My therapist helped me feel comfortable and at ease.	1	2	3	4
I felt that I was treated with respect.	1	2	3	4
My therapist was qualified to treat me.	1	2	3	4
The treatment I received was helpful to me.	1	2	3	4
I would recommend this therapist to a friend/family member.	1	2	3	4

If you were satisfied with the therapy services you received, please describe your experience in a testimonial!

May we publish your testimonial -- without identifying information -- on our website or other marketing materials? *

Yes

No

What did you find most helpful about therapy with your therapist?

Do you have any constructive feedback based on your experience? Is there anything your therapist, or we as a practice, can do better?

Email Address: *