Midwest Center for Youth and Families Survey
RequiredRequired Question(s)
1.
How long have you been referring patients to our facility?
Less than 6 months
6 months to less than 1 year
1 year to less than 3 years
3 years to less than 5 years
5 years or more
2.
How often do you refer patients to our facility?
Weekly
Twice a month
Monthly
Every few months
1 - 2 times annually
3.
How would you rate your overall level of satisfaction with us?
Highly satisfied
Somewhat satisfied
Neutral
Somewhat dissatisfied
Highly dissatisfied
4.
How do we rate on the following attributes?
 Well Below Average Below Average Average Above Average Well Above Average 
Customer service experience
Communication regarding patient
Professionalism
Quality of service
5.
How do we rate in comparison to other companies that offer the same services?
Much higher
Somewhat higher
Same
Somewhat lower
Much lower
Don't know
6.
How likely are you to continue using our services?
Very likely
Somewhat likely
Neutral
Somewhat unlikely
Very unlikely
7.
Do you have any suggestions for improvement?
 

350 characters left.
Required 8.
Please enter the information indicated below.

First Name:
Last Name:
Company Name:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code: