Patient Experience Survey
Name (optional)
First Name
Last Initial
Which location are you sharing your feedback about:
Please Select
Sunol Hills at Ridgeview
Sunol Hills at Oakview
Sunol Hills at Fremont
Mid-Peninsula Eating Disorder Center
Virtual Program
Are you a patient who received treatment or a caregiver?
Please Select
previous patient
caregiver
Please describe your treatment experience:
Rows
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Staff were respectful and non-judgemental
I felt comfortable with the safety of the environment
Staff were sensitive to my cultural background (race, religion, language, etc.)
Did you benefit from participating in the treatment program?
Were family program/services made available to you?
The staff answered all of my treatment questions
I had a positive relationship with my treatment team.
During my counseling sessions, I felt heard, understood and respected by my therapist.
During my dietary counseling sessions, I felt heard, understood and respected by my dietitian.
I felt comfortable discussing with staff any problem I encountered.
I actively participated in developing my treatment goals.
I reached my treatment goals.
I was satisfied with the discharge planning process.
How likely are you to recommend this program to a family or friend?
Not at all likely
1
2
3
4
5
6
7
8
9
Very likely
10
1 is Not at all likely, 10 is Very likely
What did you like best about the program? Any recognitions you would like to share?
What areas of improvement would you like to suggest for the services received?
Would you like to be contacted to share more information about your experience or provide a testimonial? If so, please choose “Yes” and provide your name and contact information.
Yes
Click this box to provide your name and contact information
By checking yes, you are allowing us to anonymously share your feedback publicly. We will never use your name or any identifying information.
Yes
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