QBHP Client Satisfaction Questionnaire

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Date: *

YYYY

Name (Optional)

Please check one *

Client (Adult)

Client (Child/adolescent)

Partent/Guardian

Required

Please use the following scale: 1= "I strongly disagree" to 4= "I strongly Agree". If the statement does not apply to you or your experience, please check N/A.

My QBHP treats me with dignity and respect *

N/A

My QBHP is culturally sensitive *

N/A

I feel my QBHP is concerned about problems presented *

N/A

The QBHP seems able to help with problems or concerns presented *

N/A

There were not too many forms to fill out at the first appointment *

N/A

The amount of time to wait for the first appointment with the therapist was not too long *

N/A

The amount of time between appointments with the therapist was not too long *

N/A

I feel the fees for service is affordable *

N/A

The hours for appointments are convenient *

N/A

The location of the office is convenient *

N/A

I receive helpful information about resources in the community *

N/A

I believe that any information shared is confidential *

N/A

I have hope that the condition, symptoms or complaints will get better *

N/A

I have seen a reduction in symptoms, complaints, or problems *

N/A

Overall, I was very satisfied with the services received *

N/A

Using any number from 0 to 10, where 0 is the worst mental health care possible and 10 is the best mental health care possible, choose the number you would use to rate all mental health services since your last visit? *

Please add any comments you wish to share about your experience:

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