Hampton University Mental Wellness Survey

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 use the drop-down menu to choose your Provider.

Session Date / Time

Date

Time

Is this your last session?

Your Experience

Overall, how would you rate your experience with us?

How satisfied were you with

	Unsatisfied	Neutral	Very Satisfied
Your Treatment	UnsatisfiedYour Treatment Unsatisfied	NeutralYour Treatment Neutral	Very SatisfiedYour Treatment Very Satisfied
Timely Session Scheduling	UnsatisfiedTimely Session Scheduling Unsatisfied	NeutralTimely Session Scheduling Neutral	Very SatisfiedTimely Session Scheduling Very Satisfied
Technology	UnsatisfiedTechnology Unsatisfied	NeutralTechnology Neutral	Very SatisfiedTechnology Very Satisfied
Program Meeting Your Needs/Expectations	UnsatisfiedProgram Meeting Your Needs/Expectations Unsatisfied	NeutralProgram Meeting Your Needs/Expectations Neutral	Very SatisfiedProgram Meeting Your Needs/Expectations Very Satisfied
Number of Sessions Offered	UnsatisfiedNumber of Sessions Offered Unsatisfied	NeutralNumber of Sessions Offered Neutral	Very SatisfiedNumber of Sessions Offered Very Satisfied

How likely are you to

	Unlikely	Neutral	Likely
Schedule a new appointment	UnlikelySchedule a new appointment Unlikely	NeutralSchedule a new appointment Neutral	LikelySchedule a new appointment Likely
Recommend this provider to others	UnlikelyRecommend this provider to others Unlikely	NeutralRecommend this provider to others Neutral	LikelyRecommend this provider to others Likely
Recommend BLHF Services to others	UnlikelyRecommend BLHF Services to others Unlikely	NeutralRecommend BLHF Services to others Neutral	LikelyRecommend BLHF Services to others Likely
Participate in another program like this	UnlikelyParticipate in another program like this Unlikely	NeutralParticipate in another program like this Neutral	LikelyParticipate in another program like this Likely

Have you scheduled a follow-up visit with this provider?

If not, do you plan to schedule a follow-up visit with this provider?

How was your experience?

We're sorry you if did not have a good experience. Please let us know how we can do better.

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