Patient Satisfaction Survey Please take a minute to provide your feedback about the care and services we provided. Over what period of time did you receive home health services from our agency?Start Date - must be mm/dd/yyyy format * Required MM slash DD slash YYYY End Date - must be mm/dd/yyyy format * Required MM slash DD slash YYYY What services did you receive from our agency? * Required Skilled Nursing Services Home Health Aide Physical Therapy Occupational Therapy Speech Therapy Alzheimers/Dementia Care Catheter Care Wound Care Pain Management Other If Other, please add any other services you received: * Required Did your nurse, therapist or aide introduced him/herself and explain the plan of care, allowing you and/or your caregiver to ask questions? * Required Yes No Not Sure Was the patient and/or the family involved in the decision making regarding the plan of care? * Required Yes No Not Sure Were you informed how to contact the home health staff after hours, on weekends and holidays? * Required Yes No Not Sure Did our staff explain your rights and responsibilities as a patient/family member? * Required Yes No Not Sure Did our staff give instructions and information in terms you could understand? * Required Yes No Not Sure Please select the staff member(s) you received care from and rate the care you received from each:Nurse * Required Excellent Good Fair Poor N/A Home Health Aide * Required Excellent Good Fair Poor N/A Physical Therapist * Required Excellent Good Fair Poor N/A Occupational Therapist * Required Excellent Good Fair Poor N/A Speech Therapist * Required Excellent Good Fair Poor N/A Social Worker * Required Excellent Good Fair Poor N/A Dietician/Nutritionist * Required Excellent Good Fair Poor N/A Other * Required Excellent Good Fair Poor N/A Please indicate any other staff from whom you received care: * Required Please select the staff member(s) you received care from and indicate their level of courtesy and respect:Nurse * Required Excellent Good Fair Poor N/A Home Health Aide * Required Excellent Good Fair Poor N/A Physical Therapist * Required Excellent Good Fair Poor N/A Occupational Therapist * Required Excellent Good Fair Poor N/A Speech Therapist * Required Excellent Good Fair Poor N/A Social Worker * Required Excellent Good Fair Poor N/A Dietician/Nutritionist * Required Excellent Good Fair Poor N/A Other * Required Excellent Good Fair Poor N/A Please indicate any other staff from whom you received care: * Required How would you rate the overall care you received from our agency? * Required Excellent Good Fair Poor N/A If a friend or family member needed home health care in the future, would you recommend our agency? * Required Yes No Not Sure We welcome any additional comments, and appreciate any recognition of members of our team.Your Information (Optional)Name First Last Email Phone