Mental Health Service Evaluation

Gender:

Male

Female

Staff member seen today:

Garner

Gilkes

Hayes

Humphris

Le

Lefeaux

Mann

Springer

Stokes

Vincent

Other Specify:

Please rate the services provided to you:

Office Staff

Courtesy
Poor 1 2 3 4 5 Excellent

Efficiency
Poor 1 2 3 4 5 Excellent

Professional Staff

Courtesy
Poor 1 2 3 4 5 Excellent

Compassion and interest in you as a person
Poor 1 2 3 4 5 Excellent

Answering questions
Poor 1 2 3 4 5 Excellent

Thoroughness in discussing your concerns and developing a plan to deal with them
Poor 1 2 3 4 5 Excellent

As a whole, how are you pleased with the Mental Health Service?

Very Displeased

Moderately Displeased

Moderately Pleased

Very Pleased

Primary reasons you use the Mental Health Service (Check all applicable):

Convenience

Confidence in Mental Health Staff

Emergency

Previous visits satisfactory

Prepaid service

Suggested by friends

Relatively Inexpensive

Other Please Specify:

Suggestions / Comments:

You may remain anonymous; however if you desire a personal response or if you have a specific complaint against a staff member, the following information is necessary.

First Name:

Last Name:

Address:

Telephone:

Email:

If you have any further questions or comments, please direct them to:

Drayton Vincent, MSW
Clinical Director, Mental Health Services
LSU Student Health Center
Room 254, Phone: 225-578-8774

THANK YOU FOR YOUR RESPONSE.