Location:  (Circle One)    Mountain View                 JMHS                    Peterstown

                                                         Parent Satisfaction Survey     

We would like to know how you feel about the services provided so we can make sure we are meeting your needs.  Your responses will be used to improve our services. Responses are kept confidential and anonymous. Thank you for your time. 

Please circle or mark the appropriate box to tell us how you think we are doing in the following areas:                    
 1.  Thinking about the services your child has received at the Wellness Center, how would you rate the following?  
      	Excellent	Very Good	Good	Fair	Poor	Not Applicable	
Convenience of hours? 							
How easy was it for your child to be seen?							
How good is the staff with children?							
Convenience of parent not having to leave work?							
Convenience of child not having to miss school?							
How well did staff communicate with parent?							
How would you rank the quality of health care?							
How would you rate the courtesy of the staff?							
How well was financial/billing information handled?							
How well was confidential information handled?  							

2. Are you the child’s:  (circle one)      Mother       Father       Step-Parent       Foster Parent       Grandparent       Other
3.  What grade is your child currently in:  (circle one?)    
Pre-K          K         1st          2nd          3rd          4th          5th          6th          7th          8th          9th          10th          11th        12th   
4.  How was your visit paid for:  (circle one?) 
          Medicare             Medicaid             WV Chips             Insurance             Self-Pay             HMO             Other  
5.  During the past year, where has your child gone the most for medical care:  (circle one?)  
Wellness Center     Emergency Room     Urgent Care    Private Doctor’s Office   Monroe Health Center      Other 
6.  Would you recommend this Wellness Center to others?       		Yes			No 
7. If you have any additional comments, please enter then below:  
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Thank you for completing our survey!!!

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