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Bennett College Mental Wellness Survey
This survey is REQUIRED after each session with your provider.
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Client ID
*
This is NOT your SSN. Refer to the registration sign-up email for your client number, if you cannot find it please type your email address here.
Email Address
*
Your Therapist / Mental Health Provider
*
-Please Choose Your Provider-
Myracle Clay-Bennett, Ellie Mental Health
Cydnia Young, Dope Soul Wellness
Keturah Davis, OIC Counseling and Wellness
Quashawn Pernell, OIC Counseling and Wellness
Cynia Black, OIC Counseling and Wellness
Roxie Sutton, Maximum Potential Counseling
Ella Smith, Reinvent Therapeutic and Consulting Services PLLC
Shannon Paige - Focused Behavioral Interventions
Please use the drop-down menu to choose your Provider.
Session Date / Time
*
Date
Time
Is this your last session?
*
Yes
No
Your Experience
*
Rate 1 out of 5
Rate 2 out of 5
Rate 3 out of 5
Rate 4 out of 5
Rate 5 out of 5
Overall, how would you rate your experience with us?
How satisfied were you with
*
Unsatisfied
Neutral
Very Satisfied
Your Treatment
Unsatisfied
Your Treatment Unsatisfied
Neutral
Your Treatment Neutral
Very Satisfied
Your Treatment Very Satisfied
Timely Session Scheduling
Unsatisfied
Timely Session Scheduling Unsatisfied
Neutral
Timely Session Scheduling Neutral
Very Satisfied
Timely Session Scheduling Very Satisfied
Technology
Unsatisfied
Technology Unsatisfied
Neutral
Technology Neutral
Very Satisfied
Technology Very Satisfied
Program Meeting Your Needs/Expectations
Unsatisfied
Program Meeting Your Needs/Expectations Unsatisfied
Neutral
Program Meeting Your Needs/Expectations Neutral
Very Satisfied
Program Meeting Your Needs/Expectations Very Satisfied
Facility/Physical Environment
Unsatisfied
Facility/Physical Environment Unsatisfied
Neutral
Facility/Physical Environment Neutral
Very Satisfied
Facility/Physical Environment Very Satisfied
How likely are you to
*
Unlikely
Neutral
Likely
Schedule a new appointment
Unlikely
Schedule a new appointment Unlikely
Neutral
Schedule a new appointment Neutral
Likely
Schedule a new appointment Likely
Recommend this provider to others
Unlikely
Recommend this provider to others Unlikely
Neutral
Recommend this provider to others Neutral
Likely
Recommend this provider to others Likely
Recommend BLHF Services to others
Unlikely
Recommend BLHF Services to others Unlikely
Neutral
Recommend BLHF Services to others Neutral
Likely
Recommend BLHF Services to others Likely
Participate in another program like this
Unlikely
Participate in another program like this Unlikely
Neutral
Participate in another program like this Neutral
Likely
Participate in another program like this Likely
Have you scheduled a follow-up visit with this provider?
*
Yes
No
If not, do you plan to schedule a follow-up visit with this provider?
*
Yes
No
How was your experience?
*
We're sorry you if did not have a good experience. Please let us know how we can do better.
Message
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