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Salem Fairview Clinic
Salem Madrona Clinic
Albany Clinic
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Patient Survey
Patient Survey
Step
1
of
5
20%
Patient’s age
Newborn – 3 years
3 years-8 years
8 years – 13 years
13 years -18 years
How did you learn about this practice (check all that apply)
Physician
Friend
Social Media
Google Search
Former Patient’s Family
Other
Was this your first experience with OT/SLP therapy?
Yes
No
Was this your first experience with this practice?
Yes
No
For what reason did your child receive therapy services?
How would you rate your overall experience:
How would you rate our overall customer service?
Inadequate
Adequate
Neutral
Very Favorable
Excellent
N/A
How easy was it to make an initial appointment?
Inadequate
Adequate
Neutral
Very Favorable
Excellent
N/A
Were all staff members courteous?
Inadequate
Adequate
Neutral
Very Favorable
Excellent
N/A
How was the convenience of the building location?
Inadequate
Adequate
Neutral
Very Favorable
Excellent
N/A
How is the building accessibility?
Inadequate
Adequate
Neutral
Very Favorable
Excellent
N/A
How would you rate the receptionist on:
Making you feel welcome?
Inadequate
Adequate
Neutral
Very Favorable
Excellent
N/A
Helpfulness?
Inadequate
Adequate
Neutral
Very Favorable
Excellent
N/A
Professionalism?
Inadequate
Adequate
Neutral
Very Favorable
Excellent
N/A
Respectfulness?
Inadequate
Adequate
Neutral
Very Favorable
Excellent
N/A
Thoroughness of obtaining all necessary information?
Inadequate
Adequate
Neutral
Very Favorable
Excellent
N/A
How would you rate the treating therapist on:
Friendliness?
Inadequate
Adequate
Neutral
Very Favorable
Excellent
N/A
Promptness of greeting for scheduled appointment?
Inadequate
Adequate
Neutral
Very Favorable
Excellent
N/A
Maintaining your/your child’s privacy?
Inadequate
Adequate
Neutral
Very Favorable
Excellent
N/A
Listening to you/your child’s needs/concerns?
Inadequate
Adequate
Neutral
Very Favorable
Excellent
N/A
Providing an adequate home program?
Inadequate
Adequate
Neutral
Very Favorable
Excellent
N/A
Additional Comments and Suggestions
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