Patients’ Choice Survey

Mind Works strives for a patient-centered culture where patients and families are empowered to have a voice in the management and delivery of their care.

As patients and family members, you are at the center of your healthcare team. Where your concerns and questions are answered with respect and empathy.

We are inviting you to complete a brief survey about your visit(s). Know that your voice matters and helps us improve the service we provide to our community. Please help us provide you with the best care possible by telling us how we’re doing and how we can improve.

Appointment Information

Appointment date

Share Your Experience

1.) Based on yours and your child’s most recent experience, how likely are you to recommend Mind Works to a friend or relative? Please select an answer with 1 being not at all and 5 being absolutely.

1 2 3 4 5

2.) How easy or difficult was it to obtain the care your child needed today? Please select an answer with 1 being extremely difficult and 5 being very easy.

1 2 3 4 5

3.) How well did the staff work together to take care of you and your child? Please select an answer with 1 being extremely poor and 5 being excellent.

1 2 3 4 5

Is there something we did particularly well?

Is there something we could improve?

About Your Provider: Rate your provider on the following

4.) Treating you with courtesy and respect? Please select an answer with 1 being extremely poor and 5 being excellent.

1 2 3 4 5

5.) Explaining things in a way you understood? Please select an answer with 1 being extremely poor and 5 being excellent.

1 2 3 4 5

6.) Listening carefully to you? Please select an answer with 1 being extremely poor and 5 being excellent.

1 2 3 4 5

7.) Overall care? Please select an answer with 1 being extremely poor and 5 being excellent.

1 2 3 4 5

Contact Information

Thank you for taking the time to provide your feedback. This will help us to continue to improve the care experience.

Sincerely,

Patient Experience Department

If you would like us to follow up with you to discuss your experience, fill out your contact information below.

Yes, please follow up with me to discuss my experience

Patient name

Phone number

Email address

Additional comments

Your information will be encrypted.