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Patient Satisfaction Survey
Thank you for participating in our Fully Alive Community Health (FACH). We hope your experience met your needs. We want to hear your feedback so we can keep improving our clinics. Please fill this quick survey and let us know your thoughts (your answers will be anonymous). Your participation in this survey is completely voluntary. All responses will remain confidential and used only for FACH purposes. No personal data will be shared with government agencies or third parties. If you have questions about this survey, please contact at info@fullyalivecommunityhealth.org
Is this your first time at our free clinic?
Yes
No
How much did the services you received today help improve your health or well-being? (1= Not much, 5= Very much)
Not Satisfied
1
2
3
4
Very Satisfied
5
1 is Not Satisfied, 5 is Very Satisfied
If this clinic hadn’t been available, how hard would it have been for you to get the care you needed? (1= very difficult, 5= not difficult at all)
Not Satisfied
1
2
3
4
Very Satisfied
5
1 is Not Satisfied, 5 is Very Satisfied
By considering overall experience with our facility, how likely would you recommend to your friends/family? (1= not likely, 5= very likely)
Not Likely
1
2
3
4
Very Likely
5
1 is Not Likely, 5 is Very Likely
Many people who experience the fires, need emotional care and support. Would you be interested in joining care and resilience group?
Yes
No
Tell me more
Provide email/phone number if you would like to be contacted to join a care and resilience group
Please rate the followings
Professionalism of the staff
1
2
3
4
5
Kindness of the personnel
1
2
3
4
5
Care provided
1
2
3
4
5
Please share any comments/suggestions
Submit
Should be Empty: