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2012
November
T
Therapy
Therapy
0%
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Hello:
You are invited to participate in our survey [Office management and professional Therapy Services]. In this survey, approximately [50] people will be asked to complete a survey that asks questions about [how we are doing]. It will take approximately 10 minutes to complete the questionnaire.
Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions.
Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact Survey administrator at 616-947-0921 or by email at the email address specified below.
Thank you very much for your time and support. Please start with the survey now by clicking on the
Continue
button below.
I Agree
How often do you receive our services?
Weekly
2 times a week
Monthly
Quaterly
What is your gender?
Male
Female
What is your marital status?
Single (Never married)
Married
Domestic partnership
Widowed
Divorced
Separated
Don’t know
What is your age?
Younger than 18
18 - 24
25 - 34
35 - 44
45 - 54
55 - 64
65 or older
Prefer not to answer
What is the highest level of education you have achieved?
Less than high school degree
High school degree or equivalent (e.g. GED)
Some college but no degree
Associate degree (e.g. AA, AS)
Bachelor's degree (e.g. BA, AB, BS)
Master's degree (e.g. MA, MS, MBA)
Professional degree (e.g. MD, DDS, JD)
Doctorate degree (e.g. PhD)
How well did our staff respond to your needs?
Below standard
Insufficient
Satisfactory
Good
Excellent
How would you rate your overall level of satisfaction with us?
Highly satisfied
Somewhat satisfied
Neutral
Somewhat dissatisfied
Highly dissatisfied
Comment:
Have you ever recommended us to others?
No, never recommended
Have recommended once or twice
Have recommended several times
How likely are you to continue doing business with us?
Very likely
Somewhat likely
Neutral
Somewhat unlikely
Very unlikely
Comments/Suggestions:
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