Thinking about your visit with the clinician you saw, how would you rate the following:

1. How long you waited to get an appointment?
   •  Poor  Fair  Good  Very Good  Excellent
2. Convenience of the location of the office
   •  Poor  Fair  Good  Very Good  Excellent
3. Getting through to the office by phone
   •  Poor  Fair  Good  Very Good  Excellent
4. Length of time waiting at the office
   •  Poor  Fair  Good  Very Good  Excellent
5. Time spent with the clinician you saw
   •  Poor  Fair  Good  Very Good  Excellent
6. Explanation of what was done for you
   •  Poor  Fair  Good  Very Good  Excellent
7. Technical skills (thoroughness, carefulness, competence) of the clinician you saw
   •  Poor  Fair  Good  Very Good  Excellent
8. The personal manner (courtesy, respect, sensitivity, friendliness) of the clinician you saw
   •  Poor  Fair  Good  Very Good  Excellent
9. The personal manner (courtesy, respect, sensitivity, friendliness) of the aide
   •  Poor  Fair  Good  Very Good  Excellent
10. The personal manner (courtesy, respect, sensitivity, friendliness) of the reception staff
    •  Poor  Fair  Good  Very Good  Excellent
11. The visit overall
    •  Poor  Fair  Good  Very Good  Excellent
12. How are questions about your bill or insurance answered?
    •  Poor  Fair  Good  Very Good  Excellent
13. Would you recommend the clinician you saw to your family and friends?
    •  Definitely Not Probably Not Probably Yes Definitely Yes
14. Would you recommend Wellington Therapy Services to your family and friends?
    •  Definitely Not Probably Not Probably Yes Definitely Yes
15. Are you (patient) male or female?
    •  Male Female
16. How old were you (patient) on your last birthday?

• Clinician who provided your care: Please selectAhr, EmilyAltenburger, RickBanish, TimBass, BrianBender, EmilyBiser, KaraBlackburn, JennyBrancheau, DawnBraun, KatlynBrehm, JohnBrewer, MarcBrown, JillCarmen, BarbClark, SarahConly, CathyDanemayer, KyleDaniels, ScottDenen, AbbieDevaney, ShannonDurrenberger, LarisaEbbeler, LizEggemeyer, StacyFisher, JillFolino, LouieForney, DustinFrye, LisaGeraci, CorrinGiordullo, ChrisGrayco, DavidHaas, JacquiHarrison, ToddHeyl, RachelHolbrook, CorrinHoleran, AdamHoliday, AndreaHoltzapfle, AndrewHowell, KeithHuston, AndreaJacobs, CoryKanoza, LorrieKlinefelter, CindyKostel, MelissaLeyland, MarianneLong, CindyLutz, KrisMalmstrom, MarkMaly, RobManning, ElizabethMartini, JohnMatson, KatieMcKibben, PatrickMcKinney, TinaMenkhaus, BillMerchant, DeanaMiller, JenMischnick, JeffMoerlein, SarahMorris, BridgetMorris, ChrisMuller, JennyMunn, ErinNeltner, AmyPauly, KristinPeters, JessiePetrey, TimPoe, KevinPoehner, KarlaQuiambao, WhitneyRace, ElizabethRapton, PetraRiesenbeck, JeffRobinso, MegRooney, MacairaRushford, KenSaunders, CatherineSeverns, ChrisSlemons, MikeSlusher, KelleySmith, LisaSmith, MaggieSpringer, PeggyStevens, StevieSweeterman, LisaTaylor, JasonTaylor, SheriTekulve, RockyTerwilliger, ShannonVoss, ErinWalter, HeatherWarm, LaurenWingert, BradyWeiss, NeilWells, DonWilson, KevinWirsing, MonicaWitterstaetter, AngieWorley, RyanZepf, KellyZiegelmeyer, Julie
• Location where you (patient) were seen: Please selectAndersonBlue AshButler CountyEastgateFitWorks (Westside)GlenwaySardinaUnion CentreWestside
• Please add any comments you may have. Thank you!