Feedback/Testimonial Form

Important Information

We do not request or post public reviews from current or former therapy clients. This form collects private feedback for quality improvement, with an optional permission section that allows us to use a de‑identified excerpt (anonymous quote) on our website or printed materials. Sharing is always voluntary and does not affect your care. Additional info: This is not a public review. This form is private and stored securely. We will never post what you share to Google. (Optional anonymous quote. If you choose to allow an anonymous quote, we’ll remove names and other identifying details and may lightly edit for length/clarity without changing meaning. You can revoke permission later (see below). No pressure.) Completing this form is entirely optional and not a condition of treatment or payment. Choosing not to participate will not impact your services with us.

Your Experience

About You

Current Client Former Client Professional Colleague Community Partner Other

Overall how satisfied are you with your experience?

1 - Very Dissatisfied 2 3 4 5 - Very Satisfied

What has felt most helpful from your experience?

Please avoid specific names, dates, or medical details. You can always share clinical details directly with your therapist in session.

What could be improved to make care easier or more effective for you?

Please avoid specific names, dates, or medical details. You can always share clinical details directly with your therapist in session.

Anything else you’d like your clinician or our team to know?

Please avoid specific names, dates, or medical details. You can always share clinical details directly with your therapist in session.

(Optional) Words We Could Share With Others

If a neighbor was deciding whether BBTS is a good fit, what short message would you want them to see?

Your words (optional)

(Free text — you can write a sentence or two we may consider as an anonymous quote.)

Optional attribution style (pick one if you’re comfortable):

No attribution ("—BBTS client") “—Jacksonville parent” “—Couples client” “—Adult individual”

Permission for Anonymous Quote (only for former clients or parents/guardians)

Authorization to use a de‑identified testimonial

By checking the box below, I authorize Better Being Therapy Services (BBTS) to use a de‑identified excerpt of my written feedback from this form as an anonymous testimonial. I understand and agree that:

BBTS will remove my name and any reasonably identifying details (e.g., specific dates, unique circumstances, locations) before use.
The excerpt may appear on BBTS’s website, printed materials, presentations, and social media. BBTS will not post my words to Google or other public review platforms.
This authorization is voluntary and not a condition of treatment or payment.
I may revoke this authorization at any time by emailing betterbeing@hushmail.com. Revocation will not apply to materials already produced or published before BBTS receives my request.
My words may be lightly edited for length and clarity without altering the original meaning.

Consent Checkbox

I consent to the de‑identified use described above.

If this form concerns a minor, only a parent/legal guardian may complete. We do not publish testimonials directly from minors.

Contact (Optional)

Name:

Email (optional, for follow-up):

Phone (optional, for follow-up):

Thank you!

Thank you for taking the time to share your experience. Your feedback helps us improve care and access for our Jacksonville community. If you need to update or revoke permissions, email betterbeing@hushmail.com

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