Referral Process Satisfaction Survey | Lorenz Clinic

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Referral Process Survey

We appreciate the relationships we have built with our community partners and your feedback enables us to better provide resources and benefits to those you serve. Please take a few minutes to provide us with your thoughts on our referral process.

For any other questions, feel free to reach out to Amy Gunderson, our Outreach Specialist and Care Coordinator.

Referral Process Satisfaction Survey

Step 1 of 2

50%

Date
MM slash DD slash YYYY
What services have you referred clients to us for?
- Child IOP (ages 8-12)
- Adolescent IOP (ages 13-17)
- Young Adult IOP (ages 18-20)
- Community-Based Therapy (CTSS)
- Early Childhood Day Treatment (ages 3-7)
- Intensive Treatment in Foster Care/CIBHS
- Medication Management
- Outpatient Psychotherapy
- Psychological Testing
- Cannot remember
Is the client/family you referred to us currently engaging in services at Lorenz Clinic?
How satisfied are you with our referral process?
- 1- Very satisfied
- 2- Somewhat satisfied
- 3- Neutral
- 4- Somewhat dissatisfied
- 5- Very dissatisfied
How easy was the referral form to navigate and complete?
- 1- Very easy
- 2- Somewhat easy
- 3- Neutral
- 4- Somewhat hard
- 5- Very hard
Overall, how satisfied are you with our services?
- 1- Very satisfied
- 2- Somewhat satisfied
- 3- Neutral
- 4- Somewhat dissatisfied
- 5- Very dissatisfied

Where did you first hear about our services?
Is there anyone else that you would recommend we reach out to about our mental health services?
Please feel free to share any other feedback about our referral process and if you would refer to us again.
If you'd like us to follow up with you for any reason, please provide your name, email address, phone number, and the name of your organization.
Name
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