Elements of Motivation- Patient and Family Satisfaction Survey
Thank you for choosing Elements of Motivation. Your complete satisfaction is important to us. By completing this survey, your feedback will help us to identify areas of strengths and areas in which improvements would help us provide the best possible services. We thank you for your feedback!

Voluntary and Confidential
• Your participation is voluntary. • All feedback received will be kept strictly confidential and will not affect your services at this agency. • This agency’s staff will NOT have access to your individual responses. Only authorized personnel from the Quality Assurance Department will see your answers. • If you prefer to complete this survey at a later time, please ask your therapist/provider for a paper survey and a prepaid return envelope, and mail your completed survey to us.

Family/Client Name(s) (optional)
Your answer
Therapist/Provider’s Name(s) (optional):
Your answer
Date Survey was completed (MM/DD/YY): *
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Role of Person Completing Survey/Relationship to Client (optional):
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