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Patient Satisfaction Survey

Please take a moment to answer a few questions about you, your visit, and your health care provider. The collected survey information is used to help us improve our service to you and to our community. We sincerely appreciate your time and effort.

1. Is someone other than the patient completing the survey? Yes No
2. Is this the patient’s first visit? Yes No
3. Gender: Female Male

4. What clinic did you visit?

Center for Psychiatric Medicine

Eye Foundation Hospital

CPP Community Mental Health Center

Other (please specify)

5. What type of Insurance coverage do you have?

Blue Cross/Blue Shield

Medicare

Medicaid

Self-Pay

Viva

Other

6. Are parking services convenient? Yes No
7. Please rate the courtesy of the reception staff. Excellent Good Fair Poor
8. Please rate the cleanliness of the clinic. Excellent Good Fair Poor  
9. How long ago did you schedule today’s visit? Less than 24 hours 1 to 2 Weeks 1 Month More than 1 Month
10. Were you satisfied with the timeliness of your appointment? Yes No
11. When I made the appointment, I was given the following information. (check all that apply)
Clear Directions
Procedure for scheduling or changing my appointment
Insurance & financial information needed
Date & time of appointment
12. Please rate the courtesy of the person who made the appointment. Excellent Good Fair Poor
13. The length of time to check in at the Clinic was reasonable? Yes No
14. How long did you wait in the reception area before being seen by your care provider?

Less than 15 minutes 30 Minutes More than one hour
15. Was your wait time in the reception area reasonable to you? Yes No
16. Please rate the courtesy of the nursing staff. Excellent Good Fair Poor

17. Who did you see on your visit?

Resident Physician

Physician

Nurse

Pharmacist

Psychologist

Other
Please indentify your care provider:

18. Did your provider spend enough time with you? Yes No
19. Did your provider involve you in your treatment planning? Yes No
20. Did your provider speak to you using words that you could understand? Yes No
21. Did your provider treat you with respect? Yes No
22. New medicines were explained to me, alternatives and side effects? Yes No
23. My provider explained any ordered tests to me. Yes No
24. My provider explained my treatment to me. Yes No
25. Please rate the courtesy of your health care provider. Excellent Good Fair Poor
26. Since beginning treatment at UAB my mental health has improved? Yes No

27. Please comment on anything else you would like to bring to our attention. (255 character limit)

Thank You For Taking The Time To Complete Our Survey

Please Click On The Submit Button Below To Enter Your Survey