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Name Gender Female Male Age 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 Date of Visit Counselor Choose One Ann Feller Madeline Kelley Lauri Meyer Jim Rugowski Anton Smets Please answer the following questions using this scale: 1 - Not at all 2 - Somewhat 3 - Yes 4 - Very much N/A - Not Applicable Was today's session helpful? 1 2 3 4 N/A Did the counselor / doctor treat you with respect? 1 2 3 4 N/A Did the office staff treat you with respect? 1 2 3 4 N/A Was your assessment fair? 1 2 3 4 N/A Comments Confirm Code
Name
Gender Female Male
Age 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99
Date of Visit
Counselor Choose One Ann Feller Madeline Kelley Lauri Meyer Jim Rugowski Anton Smets
Please answer the following questions using this scale: 1 - Not at all 2 - Somewhat 3 - Yes 4 - Very much N/A - Not Applicable
Was today's session helpful?
1
2
3
4
N/A
Did the counselor / doctor treat you with respect?
Did the office staff treat you with respect?
Was your assessment fair?
Comments
Confirm Code