Consumer Satisfaction Survey

Email (optional)

Age(Required)

Gender(Required)

Other

Race / Ethnicity(Required)

Other

Which program are you providing feedback on?(Required)

Who are you providing feedback on?(Required)

You can name the provider below:

Please rate the following:(Required)

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree	N/A
My provider treats me / my child with courtesy and respect.
My provider cares about my / my child's treatment goals.
I trust my / my child's provider.
The services I / my child receive(s) from the provider are helpful.
My provider listens carefully to my / my child's concerns & questions.
My / my child's goals and the provider’s goals are in line.
I am seeing progress made towards my / my child's goals.
I /my child feel(s) safe and secure attending appointments.
The waiting room was clean and comfortable.
The front desk staff are friendly and courteous.
Scheduling appointments is easy.
Rescheduling appointments is easy.
I / my child would recommend Haven House to a friend or family member.
Telehealth appointments are easy to access.

What do you like about Haven House?

Where can we improve?