Feedback and Complaints Form

Your Information

Full Name

Contact Email

Phone Number

Date of Service (if applicable)

Feedback/Complaint Details

Nature of Feedback/Complaint:

Compliment

Suggestion for Improvement

Complaint

Other (Please specify)

Details of Your Experience:

Please provide a detailed description of your experience, suggestion, or the issue you are facing. Be as specific as possible to help us understand your perspective and address your feedback or complaint effectively.

Service/Staff Involved (if applicable)

Therapist/Counselor Name

Other (Please specify)

Reception/Front Desk

Billing Department

Outcome Desired

What would you like to see happen as a result of this feedback or complaint? Please specify any particular actions or resolutions you are seeking.

Preferred Method of Contact for Follow-Up

Phone Call

Additional Comments:

No Follow-Up Needed

If there is any other information you would like to provide, please use the space below

By submitting this form, I confirm that the information provided is accurate and true to the best of my knowledge.

Signature

Date

Online Therapy for PA and NJ Residents