You or a member(s) of your family have recently completed a course of treatment at Birmingham Maple Clinic. In order to help us monitor and improve the quality of service we provide, we would appreciate it if you would take a few minutes to respond to the following questions. Your responses will be entirely confidential.
Please rate the following questions on a scale of 1 to 5, with 1 being very low and 5 being very high.

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* About your first contact with us:

  1 2 3 4 5
1. Did you receive prompt attention when you first contacted us?
2. Were your questions handled in a courteous manner?
3. Was your first appointment scheduled within a reasonable time?

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* About our facility:

  1 2 3 4 5
1. Were you satisfied with our office's physical set-up?
2. Was the setting helpful in promoting: A sense of confidentiality?
3. Comfort and security?

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* About our business office management:

  1 2 3 4 5
1. If you needed to interact with our business office, were you treated with respect and good customer service?
2. Were your messages returned in a timely fashion?
3. Were your bills and other financial information clear and easy to understand?
4. Were requests for information about your bill handled to your satisfaction by our business office?

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* About the service you received from your therapist:

  1 2 3 4 5
1. Do you feel you were treated with respect by your therapist?
2. Do you feel that the information you gave about yourself was handled in a confidential manner?
3. Did you talk with your therapist to determine issues you will be working on in therapy?
4. Were the goals for your therapy clear?
5. Were you kept informed about your progress?
6. Were you able to ask your therapist questions about your treatment?
7. Was treatment closure handled in a supportive manner?
8. Did you find the treatment helpful?

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* Summary:

  Yes No
1. Was Birmingham Maple Clinic able to meet your needs?
2. Would you return in the future if you needed to?
3. Would you recommend Birmingham Maple Clinic to a family member, friend or colleague?

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* Please list any factors which may have interfered with your receiving services:

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* Please add any additional comments you may have?

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* How did you learn about Birmingham Maple Clinic?

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* Gender

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* Race/Ethnicity:

Thank you again for your participation. Your responses will continue to help us monitor and improve the services we provide.

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