Feedback Satisfaction Survey - Wellspring Home Health Center

Over what period of time did you receive home health services from our agency?

Start Date*

End Date*

What services did you receive from our agency?*

If Other, please add any other services you received:*

Did your nurse, therapist or aide introduced him/herself and explain the plan of care, allowing you and/or your caregiver to ask questions?*

Was the patient and/or the family involved in the decision making regarding the plan of care?*

Were you informed how to contact the home health staff after hours, on weekends and holidays?*

Did our staff explain your rights and responsibilities as a patient/family member?*

Did our staff give instructions and information in terms you could understand?*

Nurse*

Home Health Aide*

Physical Therapist*

Occupational Therapist*

Speech Therapist*

Social Worker*

Dietician/Nutritionist*

Other*

Please indicate any other staff from whom you received care:*

Nurse*

Home Health Aide*

Physical Therapist*

Occupational Therapist*

Speech Therapist*

Social Worker*

Dietician/Nutritionist*

Other*

Please indicate any other staff from whom you received care:*

How would you rate the overall care you received from our agency?*

If a friend or family member needed home health care in the future, would you recommend our agency?*

We welcome any additional comments, and appreciate any recognition of members of our team.

Name

Email

Phone