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Duke Ellington Mental Wellness Survey
Duke Ellington's 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-
Dr. Lisa Pittman, Ph.D.|LePiatz Psychology, LLC
Victoria Griffin, LPC | Resiliency Counseling, LLC
Dr. Seleena Smith|REAL Liberation Coaching & Consultation Services
Petrina L. Williams LICSW, LCSW-C | Miracles In Motion Therapy and Consulting LLC
Montrella Cowan, MSW, LICSW | Affinity Health Affairs, LLC
Transcend Clinical Services, Inc
Dea Lott - DivineSense
Candyce "Ce" Anderson, LPC|Revita Therapy and Wellness
Niyama Yogi Traveler, LLC
Razaria Best, LMFT|Knowledge Therapy For Thoughts, LLC
Pieces of Me Behavioral Health, LLC
Kayla Harley|Founder of The Beebodi Marketplace, Holistic Wellness Practitioner, Breathworker & Somatic Movement Therapist
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
Number of Sessions Offered
Unsatisfied
Number of Sessions Offered Unsatisfied
Neutral
Number of Sessions Offered Neutral
Very Satisfied
Number of Sessions Offered 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.
Phone
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