Name

First Name

Last Name

1. How was your overall experience with your therapist during your pre-op psychological evaluation?

1-5 rating scale (1- awful, 5 Excellent)

2. Were you comfortable speaking to the evaluating clinician?

1-5 rating scale (1- awful, 5 Excellent)

3. Were you told about individual support/educational groups by your therapist?

Yes/No

4. What was your experience getting setup for your evaluation? (ex: scheduling, insurance gathering, appointment confirmation, payment process etc.)

1-5 rating scale (1- awful, 5 Excellent)

5. Would you recommend The Counseling Center for Change to other for their pre-op psychological evaluation?

1-5 rating scale (1- awful, 5 Excellent)

6. How was your overall experience with The Counseling Center for Change?

1-5 rating scale (1- awful, 5 Excellent)

7. Is there anything else that you would like to share with our team about your Psychological Evaluation?

8. Would you like to share a review for our website?

Monday – Friday: 9AM – 5PM
Saturday: Closed
Sunday: Closed

909 Baltimore Blvd. Suite 128.
Westminster, Maryland 21157