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 WATERS

In 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.

INSTRUCTIONS

We ask that you be completely honest in your answers. Please hit the SUBMIT button at the after completing the survey.
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2_a. What type of company, agency, or organization do you represent?

REFERRAL PROCESS QUESTIONS AND RATING

3_a. What services have you referred to Still Waters?
Check all that apply.

4. Were you notified that Still Waters received your referral?

5. Did you receive a copy of an Authorization for Release of Information for the individual you referred, if necessary?

6. Did you receive a copy of the individual’s treatment plan, if necessary?

7. Did you receive updates regarding the individual(s) you referred to this agency?

8. Overall, how would you rate your experience with the referral process?

COUNSELOR RATING

9. 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.)?
10. How would you rate the overall effectiveness of the counseling services for the individual whom you referred received from Still Waters?

OFFICE PERSONNEL RATING

Front 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.)?

STILL WATERS OVERALL COMPANY RATING

12. How would you rate your level of satisfaction with Still Waters, as a company?
13. How likely are you to refer someone else to Still Waters
Please list any experiences (positive or negative) concerning the Still Waters referral process, counselors, office personnel, and company.
Please provide us with any suggestions on ways we can improve.