Customer Service Feedback Form
Thank you for choosing YOU. We are intentional about providing you with the best care. Please complete this form so that we can determine our strengths and areas of opportunity. If you have questions, please email support@intentionalheartscc.com
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Who provided services for you today? *
What services do/did you receive today? (Select all that apply) *
What was the primary focus of your service today? *
How would you rate your service today? *
Poor
Excellent
How much do you agree with the following statements? *
0 - Does not apply to me
1 - Strongly Disagree
2 - Disagree
3 - Agree
4 - Strongly Agree
I felt welcomed to my session today
The counselor(s) effectively managed the session time
The counselor(s) challenged me in a supportive way
Attending this session was beneficial to me
I feel heard and understood by the counselor(s)
The counselor(s) displayed knowledge about the areas I needed to discuss
I would refer a family member or friend here if they needed help
Would you like to provide additional information or comments? *
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