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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.

    Strongly Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree

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

    Strongly Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree

3. I Believe the Visits Have Been Useful.

    Strongly Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree

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

    Strongly Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree

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

    Strongly Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree

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

    Strongly Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree

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

    Strongly Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree

8. I Would Seek CAPS' Services Again.

    Strongly Disagree
    Disagree
    Neither Agree Nor Disagree
    Agree
    Strongly Agree

I Am A:

Name Of The Therapist I Talked To:

Location at Which I Received Services:

Dates Of Service:

From:        To:  

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

Name:        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