Feedback - Sound Expression

Feedback Number

What type of feedback would you like to give?*

Exiting client

1. How satisfied are you with our service?*

Very satisfied
Satisfied
Unsatisfied

2. How long did the client receive music therapy for?*

1 - 10 weeks
2 – 6 months
6 -12 months
1 year +

3. Did the client attend regularly?*

Attended up to 50% of sessions
Attended up to 75% of sessions
Attended 90% + of sessions

4. What was the reason for referring the client to music therapy?*

Current client:

1. How satisfied are you with our service?*

Very satisfied
Satisfied
Unsatisfied

2. How long has the client been receiving music therapy?*

1 - 10 weeks
2 – 6 months
6 -12 months
1 year +

3. Does the client attend regularly?*

Attended up to 50% of sessions
Attended up to 75% of sessions
Attended 90% + of sessions

4. What is the reason for referring the client to music therapy?*

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Please specify:*

5. Have the goals of therapy been achieved to your satisfaction?*

6. What has the client gained most out of his/her time with us?*

7. What has the client gained least out of his/her time with us?*

8. How can we improve our service for future clients attending Sound Expression?*

9. Any other comments?

General Feedback and Complaints

If you would like to offer some general feedback or make a complaint:

Are you providing feedback/making the complaint on behalf of another person?*

Yes
No

Other Person's Details

Please fill out the details of the person you are providing feedback for.

Name of person:*

What is your relationship to the person?*

Does the person know you are making this complaint/providing feedback?*

Yes
No

Does the person consent to the complaint/feedback being made?*

Yes
No

Your Details

If you prefer to remain anonymous, you do not need to complete this section.

Your Name:

Phone:

Email:

Would you like us to contact you to discuss this feedback?

Yes
No

Tell us your feedback/complaint

What is your complaint/feedback about?*

Please provide some details to help us understand your concerns. You should include what happened, where it happened, the time it happened and who was involved.

What outcomes are you seeking as a result of the feedback/complaint?

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Name

This field is for validation purposes and should be left unchanged.

EXPRESS YOURSELF THROUGH MUSIC