SURVEY - REFERRAL SOURCE Still Waters Professional Counseling Services, Inc. (Still Waters) 3711 Executive Center Dr. • Augusta, GA 30907 Office: 706-955-9224 • Fax: 706-955-9349 THANK YOU FOR REFERRING INDIVIDUALS TO STILL WATERSIn an effort to keep our services exceptional, we occasional request our referral sources to give us feedback. Please take a few moments to rate your experience during your time with Still Waters. Be assured that your responses will be kept anonymous and in the strictest of confidence.INSTRUCTIONSWe ask that you be completely honest in your answers. Please hit the SUBMIT button at the after completing the survey.1. Date of Survey: MM slash DD slash YYYY 2_a. What type of company, agency, or organization do you represent? DFCS DJJ Hospital Doctor/Physician Group Home School GCAL MAC NEECO NYAP Other (please list) 2_b. Describe other: REFERRAL PROCESS QUESTIONS AND RATING3_a. What services have you referred to Still Waters?Check all that apply. (IFI) Intensive Family Intervention (CSI) Community Support Individual Individual or Family Counseling Bariatric Assessment FVIP Program Other (please specify) 3_b. Other referred service: 4. Were you notified that Still Waters received your referral? Yes No 5. Did you receive a copy of an Authorization for Release of Information for the individual you referred, if necessary? Yes No 6. Did you receive a copy of the individual’s treatment plan, if necessary? Yes No 7. Did you receive updates regarding the individual(s) you referred to this agency? Yes No 8. Overall, how would you rate your experience with the referral process? 1) Poor 2) Fair 3) Good 4) Great 5) Excellent COUNSELOR RATING9. How would you rate your level of satisfaction with Still Waters counselor(s) in regards to customer service (i.e. making appointments, friendliness, professionalism, etc.)? 1) Extremely Dissatisfied 2) Moderately Dissatisfied 3) Neutral 4) Moderately Satisfied 5) Extremely Satisfied 10. How would you rate the overall effectiveness of the counseling services for the individual whom you referred received from Still Waters? 1) Extremely Dissatisfied 2) Moderately Dissatisfied 3) Neutral 4) Moderately Satisfied 5) Extremely Satisfied OFFICE PERSONNEL RATINGFront Desk, Administrative Staff, Directors, Managers, CEO, Team Leads (not Counselors)11. How would you rate your level of satisfaction with the office personnel in regards to customer service (i.e. making appointments, friendliness, professionalism, etc.)? 1) Extremely Dissatisfied 2) Moderately Dissatisfied 3) Neutral 4) Moderately Satisfied 5) Extremely Satisfied STILL WATERS OVERALL COMPANY RATING12. How would you rate your level of satisfaction with Still Waters, as a company? 1) Extremely Dissatisfied 2) Moderately Dissatisfied 3) Neutral 4) Moderately Satisfied 5) Extremely Satisfied 13. How likely are you to refer someone else to Still Waters 1) Extremely Unlikely 2) Moderately Unlikely 3) Neutral 4) Moderately Likely 5) Extremely Likely 14. Comments:Please list any experiences (positive or negative) concerning the Still Waters referral process, counselors, office personnel, and company.15. Is there anything that would have made your experience with Still Waters better?Please provide us with any suggestions on ways we can improve. Δ
