Patient Satisfaction Survey

1
Overall, how satisfied are you with the services provided by Raleigh Wellness & Behavioral Health?* This field is required.
1
2
3
4
5
very satisfied
2
Patient name
First Name
Last Name
3
What could we do to improve?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
4
Would you like to provide your name?
Yes
No, remain anonymous
5
Patient Name
First Name
Last Name
6
Google Reviews! We love them! We need them! If you are willing to leave a Google review, you will be entered for a chance to win a $100 Amazon gift card (raffle is done 1 per month) - if YES, click "YES" and "SUBMIT"- below and you will be redirected to Google.* This field is required.
YESNO
Should be Empty: