Prince George County Mental Wellness Client Survey

Name *

First

Last

Client ID *

This is NOT your SSN. Refer to the registration sign-up email for your client number, please use the full ID numbers and letters.

Email Address *

Your Therapist / Mental Health Provider *

Please use the drop-down menu to choose your Provider.

Session Date / Time *

Date

Time

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

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 to others	UnlikelyRecommend BLHF to others Unlikely	NeutralRecommend BLHF to others Neutral	LikelyRecommend BLHF to others Likely

Have you scheduled 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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BLHF is a registered 501(C)3 nonprofit EIN 82-3814846