Client Survey

Please correct the errors described below.

Hello! We are very interested in receiving your feedback on how we can improve your overall experience at 515 Therapy and Consulting. Please fill out our brief 10 question survey. The data received will be used to enhance our clinical and administrative services. If you are being treated by multiple providers at our practice, please fill out one form for each clinician.

Your Name (not required)

Your Provider's Name (this helps us provide feedback and support to 515's providers)

I feel comfortable and connected with my provider.

Strongly Disagree Disagree Neither Agree/Disagree Agree Strongly Agree

My provider is a warm, caring person.

Strongly Disagree Disagree Neither Agree/Disagree Agree Strongly Agree

The service I am receiving from this provider is helping me get better.

Strongly Disagree Disagree Neither Agree/Disagree Agree Strongly Agree

I am satisfied with my provider’s availability for appointments.

Strongly Disagree Disagree Neither Agree/Disagree Agree Strongly Agree

My sessions typically start at or near my scheduled appointment time.

Strongly Disagree Disagree Neither Agree/Disagree Agree Strongly Agree

My provider is communicative and engaged.

Strongly Disagree Disagree Neither Agree/Disagree Agree Strongly Agree

Please rate your overall relationship with your provider on a scale from 1-10.

1 2 3 4 5 6 7 8 9 10

How likely are you to recommend your provider at 515 Therapy & Consulting to a friend?

1 2 3 4 5 6 7 8 9 10

Please share any additional thoughts about your experience, including what went well or what we could improve. Detailed feedback helps us better understand your experience and identify meaningful ways to improve the care and services we provide.

Your feedback is important to us and helps us improve the care and services we provide. Your individual responses will remain confidential and will not be shared outside of 515 Therapy & Consulting unless you specifically give us permission below.

Yes, I give 515 Therapy & Consulting permission to anonymously share excerpts from my written comments on our website, social media, or other marketing materials. My name and identifying information will not be included. Giving permission is completely optional and will not affect your care in any way.

No, I would not like my comments shared publicly (even without identifying information).

Thank you, we sincerely appreciate your feedback!

Your information will be encrypted.

Loading...

Electronic signature

Your browser does not support capabilities required for electronic signatures.

Close

Loading templates...

Use existing signature
Type the signature
Draw
Upload an image

Click a signature you want to use:

Drop image file here or click to select file Click here to select image file from your computer

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Use this signature or Cancel

Hushmail

Copyright © 1999-2026 Hush Communications Canada Inc.

Terms of service
Privacy policy

Hide