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Holiday Blues Group Survey
Holiday Blues Group Quality of Service Survey
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Please enable JavaScript in your browser to complete this form.
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Step
1
of 2
Informed Consent and Participation Agreement
I acknowledge by participating in the free group session sponsored by the Boris L. Henson Foundation, I authorize sharing my registration and its contents (referral) with my chosen provider and/or company. Questions regarding your HIPAA patient rights, responsibilities, and/or release of information must be sent to your treating provider if desired. I acknowledge and give permission for any and all information associated with my registration to be used by the Boris L. Henson Foundation strictly for billing, statistics, and quality assurance. I acknowledge that service fees for special exceptions, insurance copay's, no-shows, and referrals to alternate providers agreed upon between me and my provider are NOT covered by the campaign. I will ensure the mandated Quality of Service Survey is submitted online after EVERY session. I acknowledge that a lack of completion may delay provider reimbursement, scheduling, and lead to removal from the campaign. Break the silence, Break the cycle! BLHF Senior Initiatives Team
Name
*
First
Last
Date of Birth
*
Month and Year (XX/XXXX)
Self-Identified Gender
*
Male, Female, Non-Binary
Email Address
*
Group Name/Group Number
*
Group Session Date / Time
*
Date
Time
Next
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 in the group
How satisfied were you with
*
Unsatisfied
Neutral
Very Satisfied
Your Facilitator
Unsatisfied
Your Facilitator Unsatisfied
Neutral
Your Facilitator Neutral
Very Satisfied
Your Facilitator Very Satisfied
Group Time
Unsatisfied
Group Time Unsatisfied
Neutral
Group Time Neutral
Very Satisfied
Group Time 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
Attend the next group session
Unlikely
Attend the next group session Unlikely
Neutral
Attend the next group session Neutral
Likely
Attend the next group session 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 to others
Unlikely
Recommend BLHF to others Unlikely
Neutral
Recommend BLHF to others Neutral
Likely
Recommend BLHF 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 committed to the next group session?
*
Yes
No
If not, do you plan to attend the remaining groups sessions?
*
Yes
No
Would you prefer to see the provider one-on-one?
*
Yes
No
How can we improve?
*
Please let us know how we can do better.
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