Individual Satisfaction Survey

Still Waters Professional Counseling Services, Inc.

Still Waters Professional Counseling Services, Inc. (Still Waters) Survey Explanation

In order to better to serve you (or the individual you represent) better, we would love your input. We will use this survey data to improve our services and customer service.

Survey Instructions

Please honestly answer all of the questions. ALL SURVEYS WILL BE HELD IN THE STRICTEST OF CONFIDENCE. You have the option to remain anonymous or to be contacted concerning your responses. Note: This survey takes less than 5 minutes to complete.
MM slash DD slash YYYY


These questions pertain to the INDIVIDUAL RECEIVING SERVICES. If you are filling out this form on behalf of the individual please use their information. Indicate you are a legal representative of the individual in question 1_1.
1_1. Please check which best describes you.
Person taking this survey. Select only one answer.
1_2. Date of Birth – of Individual Receiving Services
1_3. Gender – of Individual Receiving Services

(2) Contact Information (Optional)

If you wish to be contacted by management concerning issues discussed in this survey, please provide name(s) and contact information below. Providing name(s) is OPTIONAL.
2_1. Desire to be contacted concerning this survey
2_2. Name – Individual receiving or has received services (Optional)
2_3. Name – Legal Representative of the Individual listed above (Optional)

(3) General Questions

Answer these questions on behalf of the INDIVIDUAL RECEIVING SERVICES.
3_1. Current status concerning receiving services?
3_2. How long have you received services from Still Waters?
3_3_a. What services are/were you receiving from Still Waters?
Select all that apply.
3_5_a. How did you hear about Still Waters?
Skip if not applicable.
Skip if not applicable.
3_6. Would you have preferred to be MORE actively involved with treatment decisions?
3_7_a. If you have experienced any out of home placements in the last 3 months, please select placement location(s).
3_8. Have you ever called the Still Waters crisis phone number?

(4) SWPCI Office Staff

Office staff refers to administrative staff like front desk, directors and managers. Exclude comments concerning your counselor(s) in this section.
4_1. Rate level of satisfaction with Still Waters OFFICE STAFF in regards to customer service?
Please rate based on issues such as making appointments, friendliness, professionalism etc.

(5) Counselor(s)

5_1. On a weekly basis, how many times did you see your counselor(s)?
5_2. Approximately how long are your counseling sessions?
5_3. Does your counselor(s) schedule appointments ahead of time?
5_4. When scheduled, does your counselor(s) show up for appointments on time (within 20 minutes of appointment time)?
5_5. To accommodate the counselors schedule, how many times in the last 3 months has your counselor cancelled or rescheduled appointments?
5_6. Rate level of satisfaction with Still Waters COUNSELOR(s) in regards to customer service.
Please rate based on issues such as making friendliness, abilities and professionalism etc.
5_7. Do you feel that you (or the individual you represent) has benefited from receiving counseling from Still Waters?
5_8. Rate the overall effectiveness of the counseling services you received from Still Waters?

(6) Telehealth Services

6_1. Have you received services using our Telehealth Service?
6_2. How would you rate the overall effectiveness of Telehealth Services?

(7) Still Waters Overall Performane

7_1. How likely are you to recommend SWPCI to someone else?
Example: Would you recommend SWPCI to a friend, relative, co-worker etc.?
7_2. How would you rate your level of satisfaction with Still Waters, as a company?
7_3. Is there anything that would (or would have) made your experience with Still Waters better?

(8) For Internal Use Only

Used for SWPCI staff, contractors and interns only.
8_1. Surveyor if other than individual.