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Intake Feedback Form
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Intake Feedback Form
Intake Feedback Form
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Email (Optional)
Leave this blank if you want your feedback to be anonymous.
Would you like an email response from the service provider?
Yes
No
the referral service
Anything you would like to say about the referral process?
What did you like, did not like, what was missing, any changes, etc.?
What type of service(s) were you seeking?
EAP
Counseling
Coaching
Consultation
Skills Training
Education
CIR/Crisis Intervention
Other
Comments about what you were looking for:
Was there anything missing or did not match such as age range, specialties, modality, etc.?
If you did not establish services, what were the reason(s)?
Found a better match elsewhere
Decided not to pursue services anywhere
Intake process too confusing or difficult
Intake paperwork too confusing or difficult
Did not agree with informed consent
Something about the service or provider I did not like
Scheduling did not work out
I thought starting would be faster or easier
Too nervous to follow through
Other
Please be specific with your thoughts about the intake process:
What did you like, did not like, what was missing, any changes, etc.?
Submit
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