Feedback Form
We are happy to hear from you regarding your experience and are eager to follow up either by sharing your praise or addressing areas of concern. Thank you for taking the time to reach out.
Please let us know the agency where this interaction/incident occurred.
North Texas Behavioral Health Authority
Child and Family Guidance Center
Homeward Bound
Southern Area Behavioral Healthcare
Other
If you answered "Other" above, please type the name of the agency here.
Please let us know the date on which this interaction/incident occurred.
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Month
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Day
Year
Date
Please let us know the approximate time when this interaction/incident occurred.
Hour Minutes
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PM
AM/PM Option
Please share the name(s) of the staff with whom you interacted.
Name(s)
Please tell us what happened.
If you are comfortable, please let us know your name.
First Name
Last Name
If you would like to be contacted as part of our response to your feedback, please provide your e-mail address and/or telephone number.
Please enter a valid e-mail address: example@example.com
Please enter a valid phone number.
Format: (000) 000-0000.
Please rate your experience during the incident in question.
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5
Please rate your overall experience with the agency where you receive services.
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Please share your thoughts on how we can improve.
recommendations for improvement
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