Radical Elevation Customer Review Form

Customer Review Form

Thank you for choosing Radical Elevation. We'd love to hear feedback from our customers. Please fill out the form below:

Date

Full Name (OPTIONAL)

First NameLast Name

Phone Number (OPTIONAL)

Please enter a valid phone number.

Email (OPTIONAL)

example@example.com

Who did you receive services for and why?

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
The program is helping to reach treatment goals.
The program addressed identified needs.
It was easy to access the program's services.
I was treated with respect from the staff.

What are the things you're satisfied with? What are the things you are not satisfied with?

Any additional comments, suggestions, or feedback?

Would you refer us to your friends, family, or colleagues?

YesNo

Would you like to receive email newsletter about our products?

Yes. I consent to Radical Elevation emailing me information relating to mental health related services, general advice, and future events or giveaways. View our privacy policy at www.radicalelevation.comNo

If yes, please ensure the email field above has been filled out with the correct information.

Please verify that you are human*