Q1. Did the office staff provide enough information about your insurance benefits & your financial responsibilities? *

Q2. Office Staff & Appointment Setting *

	Excellent	Very Good	Good	Fair	Poor
1. Courtesy of staff at the front desk
2. Responsiveness of staff regarding your initial need for information & scheduling
3. Convenient appointment times when scheduling

Q3. Your Therapist *

	Strongly Agree	Somewhat Agree	Agree	Somewhat Disagree	Strongly Disagree
1. Was Courteous
2. Spent appropriate amount of time with me
3. Was knowledgeable & explained my condition/injury to me
4. I trusted his/her decisions
5. Listened well & answered questions
6. Understood my concerns

Q4. Who Was your therapist? Check all that apply

Q5. Did you reach a favorable outcome regarding your injury/conditions? *

Q6. On a scale of 0-10, how likely are you to return for care or refer family or friends to our clinic? (0 being not going to refer and 10 referring everyone.) *

Q7. If you did not give us a 10, what could we improve to earn a 10?

Q8. Age in years: *

Q9. Was this your first experience with Physical Therapy? *

Q10. Was this your first experience with our clinic? *

Q11. Which Clinic did you Participate in PT? *

Q12. How did you learn about this facility? *

Friend	Insurance Company	Social Media (i.e twitter, facebook, etc)
Internet	Telephone Book	Physician

Q13. Describe your best experience you had doing therapy with us or any other comments.

Q14. If you would like a response to this survey or further information from CPR, please provide your best contact information.

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