We value your input and suggestions and constantly strive to improve our services.
Thank you for taking the time to complete this questionnaire.
1. Is someone other than the consumer completing the survey? Yes No

2. Is this the consumer’s first visit? Yes No

3. Gender: Male Female

4. What location where you seen at? North Andover Lawrence

5. What type of Insurance coverage do you have?

Blue Cross/Blue Shield
Private Insurer

6. Are parking services convenient? Yes No

7. Please rate the courtesy of the reception staff. Excellent Good Fair Poor

8. Please rate the cleanliness of the Practice. Excellent Good Fair Poor

9. How long ago did you schedule today’s visit? Less than 24 hours 1 to 2 weeks 1 month More than 1 month

10. Were you satisfied with the timeliness of your appointment? Yes No

11. When I made the appointment, I was given the following information. (check all that apply)

Clear Directions
Procedure for scheduling or changing my appointment
Insurance & financial information needed
Date & time of appointment

12. Please rate the courtesy of the person who made the appointment. Excellent Good Fair Poor

13. The length of time to check in at the Practice was reasonable? Yes No

14. How long did you wait in the reception area before being seen by your care provider?

Less than 15 minutes
30 minutes
More than an hour

15. Was your wait time in the reception area reasonable to you? Yes No

16. Please rate the courtesy of the clinical staff. Excellent Good Fair Poor

17. Who did you see on your visit?


18. Optional: Who is your care provider:

19. Did your provider spend enough time with you? Yes No

20. Did your provider involve you in your treatment planning? Yes No

21. Did your provider speak to you using words that you could understand? Yes No

22. Did your provider treat you with respect? Yes No

23. New medicines were explained to me, alternatives and side effects? Yes No

24. My provider explained any ordered tests to me. Yes No

25. My provider explained my treatment to me. Yes No

26. Please rate the courtesy of your health care provider. Excellent Good Fair Poor

27. Since beginning treatment at the Center for Psychiatric Medicine, my mental health has improved? Yes No

28. Please comment on anything else you would like to bring to our attention.

Questions? Call 978-685-8800 | Fax: 978-685-8808 | Center for Psychiatric Medicine 290 Merrimack Street, Lawrence, MA 01843
Specializing in Neuropsychiatry, Psychopharmacology, Individual and Group Psychotherapy, Family and Couple’s Psychotherapy, Youth and Adolescent services,
Cognitive Behavioral Therapy, Dialectical Behavior Therapy, Dual Diagnosis, Psychological and Neuropsychological Testing, Memory Evaluations and Boredom Management