Customer Satisfaction Survey Form

Overall satisfaction of service

	YES	NO	N/A
Are you satisfied with your current counseling services?
Are you satisfied with your current psychiatric services?

How would you rate the professionalism of the counselors on a scale of 1-5 with 5 being the highest?

	1	2	3	4	5

1 is Worst, 5 is Best

How would you rate the quality of services delivered on a scale of 1-5 with 5 being the highest?

	1	2	3	4	5

1 is Worst, 5 is Best

Overall satisfaction of staff

	YES	NO
Do you feel your staff is reliable?
Is your expectation of services being met?
Is the staff sensitive to cultural issues and providing services that meet your cultural needs?

For Clients in Services