Quality Assurance Form - Print and sign then turn in within 24hrs.

Client Name:

Person Contacted:

Phone Number:

QA Month:

Counselor:

Date:

Time:

Email:

Office Location:

Submitted By:

Are you satisfied with our service?

How would you rate our counselor's performance? 1-10, 10 BEING BEST

How likely are you to recommend our program or services?

How long have you been a client? Do you see any change sience beginning treatment?

Are we accommodating, can you reach your counselor on short notice?

Is your child in active therapy?

If so who is the therapist?

Do you sign off on our encounter log when the Counselor see's your child/client?

Do you have any suggestion on improvement of our services?

Are there any areas in which you would recommend change?

Notes & Comments from parents/clients