INDEPENDENT PRACTITIONER SURVEY


Please answer the questions below based on your experiences with Sims Consulting & Clinical Services


Demographic Information

Cabarrus

Rowan

Guilford

Mecklenburg

Davidson

Forysth

Union

Other



Gender

Male

Female

Age of person receiving services:



Person completing the form is:

Receiving services

Guardian/Family Members



Race:

American Indian, Alaskan Native

Asian

Black, African American

Hispanic, Latino

White

Other

Please Specify

 

 


I was able to get a routine appointment in a timely manner.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Unsure



I have never had to wait more than 15 minutes past my appointment.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Unsure



I am able to call during office hours and get the help or advice that I need.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Unsure



The Provider listens carefully to my needs.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Unsure



The Provider speaks and explains things in a way that I can understand.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Unsure



The Provider shows respect for what I have to say.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Unsure



The Provider spends an appropriate amount of time with me.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Unsure



Office staff treated me with courtesy and respect.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Unsure



Office staff was very helpful to me and my family.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Unsure



Provider is very knowledgeable of my specific condition/needs

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Unsure


If a friend asked, I would recommend this provider/agency.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Unsure



Overall I am satisfied and feel comfortable with this Provider.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Unsure



Due to this Provider, I have a better quality of life

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Unsure

 

Please list any strengths the provider/agency demonstrates:


Please list any weaknesses the provider/agency has:


Please list any other information you would like to share in the comments section below:

If you would like our Quality Management Department to call you about this survey please give us the information below:

Name of person to call:

Phone#:

Reason you would like to talk to someone: