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Treatment Program Feedback Form
Thank you for providing treatment program feedback. Your comments may be edited for clarity, grammar, and conciseness before being shared publicly. Please note that while all reviews are appreciated, not all may be made public.
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Name
*
First
Last
Name of Treatment Program or Facility
*
Did you feel confident in this program/facility’s ability to treat your loved one?
Yes
No
It's Complicated
Please explain your answer below:
On a scale of 1-10, please rate the following:
Selected Value:
0
Quality of care received
On a scale of 1-10, please rate the following: (copy)
Selected Value:
0
Effectiveness of treatment
On a scale of 1-10, please rate the following: (copy) (copy)
Selected Value:
0
Professionalism of the staff
On a scale of 1-10, please rate the following: (copy) (copy) (copy)
Selected Value:
0
Communication with family members
On a scale of 1-10, please rate the following: (copy) (copy) (copy) (copy)
Selected Value:
0
Ease of admission process
Describe any support that people other than the patient (e.g. family support, therapy, peer support) received during/after your loved one’s treatment.
Describe the program/facility employees’ sensitivity to your Jewish observance.
If you participated in a step down model (from Hospitalization to Partial Hospitalization to Intensive Outpatient treatment) how seamless was the transition as your care continued?
When your loved one completed treatment, were they well supported in their transition into outpatient care?
Would you be open to connecting with other families who are interested in discussing the program?
Yes
No
Single Line Text
Would you be open to being included on a PUBLIC list of people to contact for more information about the program?
Yes
No
Would you be open to being included on a PRIVATE list of people to contact for more information about the program?
Yes
No
Single Line Text (copy)
Submit
