LifeBridge: Wellness Program - Participant Survey
The information collected on this form is useful for the DCMS Foundation to know how to best provide services to our members.
Please Tell Us About Your Experience with the Program:
Was this a:
First Time Session
Follow-Up Session
Month of Visit:
Who Was Your Counselor?
Diana Davis, LMHC
Steve Seay, M.A., PCC
Arianne Smith, LMHC
Mia Wilson, LMHC, PHD
Accessing the program and getting set up with a counselor went well.
Yes
No
The counselor was able to offer me an appointment time that worked for me.
Yes
No
The session was held:
In-Person
Via Phone/TeleHealth
If in-person, was the location convenient? (Skip question if phone/ telehealth)
Yes
No
The counselor was easy to talk to.
Yes
No
My meetings with this counselor have been helpful.
Yes
No
I plan to continue seeing this counselor.
Yes
No, not satisfied with visit.
No, services no longer needed.
I would recommend this counselor to my colleagues or patients.
Yes
No
Would you be willing to provide a quote/ share your experience as a testimonial for other society members? If yes, please provide your name and email address.
Yes
No
If Yes, Provide Name and Email Address, Along with Your Testimonial to Share: (Leave Blank If No)
Comments or Suggestions:
Basic Demographics
Age:
25-43
44-57
58-70
71+
Gender:
Male
Female
Member of:
Duval CMS
Clay CMS
Nassau CMS
Other Society
Employment Status:
Practicing
Resident/Fellow
Retired
Submit
Should be Empty: