Thomas Deshler Ph.D. P.C
Safe Place to Talk at
Willamette Valley Family Center, LLC
610 Jefferson Street, Oregon City, Or. 97045
(503-657-7235)

CLIENT FEEDBACK FORM

I need your help so that I can serve you better. I want to know how you have been treated at Willamette Valley Family Center. Please take a few moments and complete the following feedback form .  Thank you.

 
Completed by:                             Client    Parent/Guardian   Other
 
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Does Not Apply
1
 I have been able to easily set an appointment for a convenient time.
2
 I have been respectfully treated by the Center office staff.
3
 I am satisfied with how you listened to my concerns.
4
 When necessary you contacted other people who were involved with my care.
5
 I have been involved in setting goals for my treatment.
6
 Overall, I am satisfied with my experience at Willamette Valley Family Center.
7
 I would recommend others.
8
 I feel I was able to achieve the changes I wanted.

9. What was most helpful about your therapy experience?

 

10. About how many sessions did you have with me?    1 - 3 4 - 6 7 - 12   more than 12

11. In order to better serve you, what improvements could we make?

 

12. If you care to give me your name and phone number, please let me know if you would like me to give you a call.

Your Name Phone E-mail