THERAPIST PERFORMANCE REVIEW

Therapist Name:

Your Appointment:

1. Ease of making appointments by phone

Perfect

Good

So-so

2. Appointment available within a

reasonable amount of time

Perfect

Good

So-so

3. Explaining things in a way you could

understand

Perfect

Good

So-so

4. Instructions regarding follow-up care

Perfect

Good

So-so

5. The thoroughness of the examination

Perfect

Good

So-so

Overall Satisfaction:

1. Our practice

Perfect

Good

So-so

2. The quality of your medical care

Perfect

Good

So-so

3. Overall rating of care from your

therapist

Perfect

Good

So-so

Would you recommend the clinician to others?

Yes

No

If no, please tell us why:

If there is any way we can improve our service to you, please tell us about it.

Your Name

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THERAPIST PERFORMANCE REVIEW

Your Appointment:

Overall Satisfaction:

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