Surveys & Forms - St. Joseph Mercy, Ann Harbor and southeast Michigan

Surveys & Forms

Outpatient Therapy Survey

Our goal is to provide you with a "Remarkable" patient care experience. With your input we hope to achieve this goal. If you would like us to contact you regarding your comments, please include your name and telephone number.

* Indicates required information

1. *

Please indicate the location where you were seen.

	E. Stadium
	Canton
	Saline
	MOC
	Woodland
	Howell
	Reichert

2. *

Please indicate the Rehabilitation Services you received.

	Occupational Therapy
	Physical Therapy
	Hand Rehabilitation
	Speech Therapy
	Work Rehabilitation
	TBI
	Lymphedema
	Neuropsychology

3. *

Would you like to be contacted to talk about your experience further?

Yes No

If yes, please indicate how we can contact you.

5. *

Did you feel that our Receptionist showed compassion for you during your therapy sessions?

Never = 1 2 3 4 = Always

6. *

Did you feel that our Aides showed compassion for you during your therapy sessions?

Never = 1 2 3 4 = Always

7. *

Did you feel that our Therapists showed compassion for you during your therapy sessions?

Never = 1 2 3 4 = Always

8. *

Did our Receptionist show concern for your privacy and dignity?

Never = 1 2 3 4 = Always

9. *

Did our Aides show their concern for your privacy and dignity?

Never = 1 2 3 4 = Always

10. *

Did our Therapists show their concern for your privacy and dignity?

Never = 1 2 3 4 = Always

11. *

Was our Receptionist cheerful and courteous?

Never = 1 2 3 4 = Always

12. *

Were our Aides cheerful and courteous?

Never = 1 2 3 4 = Always

13. *

Were our Therapists cheerful and courteous?

Never = 1 2 3 4 = Always

14. *

Would you return to our clinic again, if you needed rehabilitation services?

Definitely Not = 1 2 3 4 = Definitely Yes

15. *

Would you recommend us to others?

Definitely Not = 1 2 3 4 = Definitely Yes

16.

Was there anything that was frustrating or disappointing in your therapy experience? What more could have been done for you?

17.

Did we do anything for you that was memorable? Is there anyone you would like to recognize?

18.

Additional Comments

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Surveys & Forms