Patient Satisfaction Survey

Treating patients relies on the support of family and friends. At Private Clinic Albany, we encourage and solicit your feedback in order to better serve our patients. Please take a moment to fill out the form below. We will not share or distribute personal information but rather use it internally.

Family Name	*required
Patient Name	*required
Relation to Patient	*required
How long has relative been in treatment at our Private Clinic Albany?	*required
Has your relative ever been in treatment before, if so type of treatment?	Yes No *required
Patient I.D.#	*required
E-Mail	*optional
Phone	*optional

Please take a few moments to answer these questions that will help us provide the best services possible to both our clients and their familes. We appreciate your time and comments.

Rate each question with the numbers 1 through 7.
Number 1 being not at all and number 7 being very much.

1)	The clinic hours fits my needs? If not, let us know in question #10.

2)	Are there groups that you feel you are interested in? If not, let us know in question #10.

3)	Do you feel your counselor is available to you when you need him/her?

4)	Has the clinic met your expectations for treatment?

5)	How satisfied are you with the services you received from the counselors?

6)	How satisfied are you with the services you received from the nurses?

7)	Do you feel counseling has helped you?

8)	Overall, are you satisfied with the services you have received from PCA?

9)	Do you feel you have been treated with dignity and respect at PCA?

10) Please add any additional comments/suggestions you may have that were not specifically addressed in the survey above.