Still Waters Professional Counseling Services, Inc. Satisfaction Survey - Referral Source

Thank you for referring consumers to our organization. In an effort to keep our services exceptional, please take a few moments to rate your agency’s experience during your time with Still Waters Professional Counseling. All surveys and responses will be kept anonymous (unless you choose to reveal your name in this survey) and in the strictest of confidence. Revised Sept. 20, 2021
2. a. What services did you refer?
Check all that apply.
3. a. Did you receive a call indicating the Company had received your referral?
Please write any comments positive or negative regarding Still Water's performance concerning providing follow-up phone calls.
4. Did you receive a copy of an Authorization for Release of Information for the individual you referred, if necessary?
5. Did you receive a copy of the individual's treatment plan, if necessary?
6. a. Did you receive updates regarding the individual(s) you referred to this Agency?
6. c. Comments concerning updates.
Please write any comments positive or negative regarding Still Water's performance concerning providing updates.

Satisfaction Rating

Please rate your satisfaction concerning the following areas:
8. a. How would you rate your level of satisfaction with the office personnel in regards to customer service (i.e. making appointments, friendliness, professionalism, etc.)?
9. a. How would you rate your level of satisfaction with the counselor(s) in regards to customer service (i.e. making appointments, friendliness, professionalism, etc.)?
10. a. How would you rate the overall effectiveness of the counseling services the person whom you referred received from Still Waters?
11. a. How likely are you to refer someone else to Still Waters Counseling?
12. Overall, how would you rate your experience with the referral process?
Please provide any questions, comments, complaints, and/or praises.