Referring Clinician Survey

E Street Supportive Housing Referring Clinician Survey

Your insights are invaluable in helping us provide the best possible care and support to both you and your patients. Thank you for taking the time to share your thoughts and feedback.
Name *

First NameLast Name
Practice Name

First NameLast Name
Email*
example@example.com
What is the name of the client you referred to Mind Therapy Clinic?
This form strictly adheres to the Health Insurance Portability and Accountability Act (HIPAA) regulations, ensuring the confidentiality and security of your protected health information (PHI). Your privacy is our utmost priority.
How did you hear about us?*

Internet SearchFriend or Family MemberHealth InsurancePrimary Care DoctorMental Health FacilitySocial MediaWord of MouthCurrent or Former Patient
How satisfied are you with the ease of referring your clients to Mind Therapy Clinic?*

Very SatisfiedSatisfiedNeutralDissatisfiedVery Dissatisfied
Are you satisfied with the coordination of care between your clinic and Mind Therapy Clinic in providing treatment to shared clients?*

Very SatisfiedSatisfiedNeutralDissatisfiedVery Dissatisfied
Are there any safety concerns for the client or others that should be addressed ?*
Are there any specific care coordination needs for this client that you would like our admissions team to address during the referral process?*
What suggestions or improvements, if any, would you recommend to enhance the referral and communication process with Mind Therapy Clinic?
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E Street Supportive Housing Referring Clinician Survey