Physician Wellness Feedback
Please take a few moments to complete this form
I am a member of:
Lee County Medical Society
Collier CountyMedical Society
Psychologist Name:
How did you learn about this benefit offered through the Physician Wellness Program?
Please rate your experience:
Very Disappointed 1
Disappointed 2
Neutral 3
Satisfied 4
Very Satisfied 5
Doctor Knowledge
Doctor Kindness
Doctor Helpfulness
Comfort talking with Doctor
Waiting Time for first appointment
I feel the problems, feelings, or situation that brought me to therapy have improved.
1
2
3
4
5
Disagree
Agree
1 is Disagree, 5 is Agree
My participation in therapy has helped me to understand my problems well enough to manage them in the future.
1
2
3
4
5
Disagree
Agree
1 is Disagree, 5 is Agree
If I need help in the future, I would feel comfortable calling this psychologist.
1
2
3
4
5
Disagree
Agree
1 is Disagree, 5 is Agree
I would recommend this psychologist to others.
1
2
3
4
5
Disagree
Agree
1 is Disagree, 5 is Agree
Any additional comments that you would like to share:
Please provide any suggestions you may have on how can we improve our service.
Submit
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