Client Satisfaction Survey

Empathy Care Customer Satisfaction Survey

Thank you for choosing Empathy Care, Inc. to provide your home health care services. As we strive to provide the highest quality, most professional service possible, we need your feedback, comments, and suggestions. Please take a few moments to complete this survey and send it back to us.

Should you need home health care at any time in the future, we would look forward to being at your service once again.

Please Check Your Choice for Each Question

1. How satisfied are/were you with the services you received?

Very Satisfied
Satisfied
Dissatisfied
Very Dissatisfied
Did Not Use
Very Satisfied
Satisfied
Dissatisfied
Very Dissatisfied
Did Not Use
Very Satisfied
Satisfied
Dissatisfied
Very Dissatisfied
Did Not Use

Very Satisfied
Satisfied
Dissatisfied
Very Dissatisfied
Did Not Use

Very Satisfied
Satisfied
Dissatisfied
Very Dissatisfied
Did Not Use

Very Satisfied
Satisfied
Dissatisfied
Very Dissatisfied
Did Not Use

2. Please rate the staff who provided these services.


Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion

Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion

Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion

Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion

Strongly Agree
Agree
Disagree
Strongly Disagree
No Opinion

3. Please rate the assistance you received from the agency staff on the telephone.

Very Satisfied
Satisfied
Dissatisfied
Very Dissatisfied
No Opinion
Very Satisfied
Satisfied
Dissatisfied
Very Dissatisfied
No Opinion
Very Satisfied
Satisfied
Dissatisfied
Very Dissatisfied
No Opinion

Very Satisfied
Satisfied
Dissatisfied
Very Dissatisfied
No Opinion

Very Satisfied
Satisfied
Dissatisfied
Very Dissatisfied
No Opinion

Very Satisfied
Satisfied
Dissatisfied
Very Dissatisfied
No Opinion


Yes
No



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