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Evaluate CAPS

Recently, you received services from a staff member of CAPS. We would value your feedback about those visits. This form can be returned to CAPS by clicking on the "Send Button" at the bottom of this form. If you choose, you may include your name and email address in the comments section if you would like to be contacted, otherwise this form has been designed to block the identity of the sender so that your feedback will be received by CAPS anonymously.

Please click on the buttons that indicates your level of AGREEMENT with each statement.

The Service I Received Was:

1. I Was Treated Courteously By The Secretary/Receptionist.

2. The Therapist Helped Me to Feel Comfortable Enough to Express What I was Thinking Most of the Time.

3. I Believe the Visits Have Been Useful.

4. I Felt the Therapist Was Appropriately Concerned About My Problem.

5. The Therapist Expressed Concern and Care for Me as a Person.

6. I Have Experienced Improvement in the Condition or Problem for Which I Sought Services.

7. I Would Refer a Family Member or Friends for Services at CAPS.

8. I Would Seek CAPS' Services Again.

I Am A:

Name Of The Therapist I Talked To:

Location at Which I Received Services:

Dates Of Service:

From: From Date To: To Date

Name and Email Address:
(Please add your name and email address if you would like to be contacted.)

Name: Name Email: Email

Additional Comments:

Thank you very much for your assistance in answering this survey.
Your comments will assist us in improving CAPS and the services we provide.

If you have any questions about this form or the answers your provided, you may send questions to the CAPS webmaster

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