LifeBridge: Wellness Program - Participant Survey
The information collected on this form is useful for the PSCF to know how to best provide services to our members. The completed form will be sent directly to the Medical Society with no identifiers, ensuring your anonymity.
Please tell us about your experience with the program. Was this a:
First Time Session
Follow-up Sesion
When was the Month of Your Visit:
Who was your counselor?
Amber Fasula, PsyD, BCN
C. Dwight Bain, LMHC, NCC, CLC
Patti Hall, MS, LMHC, CSAT, CAC
I don't remember
Accessing the program and getting set up with a counselor went well:
Yes
No
The counselor was able to offer me an appointment time that worked for me.
Yes
No
The session was held:
In-person
Via phone/TeleHealth
If in-person, was the location convenient? (Skip question if phone/telehealth)
Yes
No
The counselor was easy to talk to.
Yes
No
My meetings with this counselor have been helpful.
Yes
No
I plan to continue seeing this counselor.
Yes
No, satisfied with visit.
No, dissatisfied with visit.
I would recommend this counselor to my colleagues or patients.
Yes
No
Would you be willing to provide a quote/share your experience as a testimonial for other society members? If yes, please provide your comments to share in the below comment box. You can give your name if you wish, but this is not required.
Yes
No
Quote of Your Experience to Share with Society Members (Optional):
Additional comments or suggestions to help improve this program:
Basic Demographics
Age:
25-43
44-57
58-70
71+
Gender:
Male
Female
Employment Status:
Practicing
Medical Student
Resident/Fellow
Retired
Submit
Should be Empty: