Client Satisfaction Survey
Which Clinician do you see?
*
Please Select
Shameka Chanel
KeShonda Gaskin
Heather Jones
How long have you been a client with Points of Origin?
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How often are your appointments?
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Weekly
Bi-weekly
Every 3 weeks
Once a month
Other
How often do you use the skills/ content from your sessions?
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Almost always
Often
Sometimes
Seldom
This is my first time
How would you improve the services you have received so far?
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What has had the biggest impact on you since beginning services?
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What has been the LEAST favorite/ most challenging part for you?
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Please rate your overall experience in terms of the following:
I felt heard/ listened to?
1
2
3
4
5
Price
1
2
3
4
5
Availability
1
2
3
4
5
Comfort
1
2
3
4
5
On a scale of 1 to 10, how satisfied are you with the customer service?
Not Satisfied
1
2
3
4
5
6
7
8
9
Extremely Satisfied
10
1 is Not Satisfied, 10 is Extremely Satisfied
Personal Information
Does the product/service help you to achieve your goals?
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Yes
No
Would you be willing to provide a written testimonial about your experience with Points of Origin?
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Yes
No
If you said yes, please provide a short, written testimonial that Points of Origin, LLC can share (2-3 sentences).
How would you like your name to be listed with the testimonial?
We often have a difficult time remembering "the simple" things so we'd like to provide an opportunity for you to share a kind word with your clinician. What would you like them to know about your experience with them?
Please share some words of encouragement that we may use to help others make a decision about beginning therapy.
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