About My Services…		Always/Usually		Sometimes		Never
I was involved in decisions about care/therapy
My clinical needs were met
I was told about changes in schedules
Clinical Personnel (therapists)…
Courteous
Caring Attitude
Knowledgeable
Neat
Office Personnel…
Courteous
Caring Attitude
Helpful
Prompt
As a result of our services…		Yes		No		Unsure
Do you know how to better care for your child?
Would you use Solace again?
Would you recommend Solace to a friend?
		Always/Usually		Sometimes		Never
Answers from office staff were understandable?
Questions answered satisfactorily?

OPTIONAL If you would like someone from the office to contact you, click here and complete info below.

Name of Client: Name of Person completing form: