Patient Satisfaction Form

NSR — Patient Satisfaction Survey — Confidential

Fields marked * are required. All information is kept strictly confidential and protected under HIPAA.

About This Survey

Thank you for choosing Next Step Rehab for your therapy. Your honest feedback is completely confidential — it is reviewed by our clinical leadership and used directly to improve the care we provide to every patient. This survey takes approximately 3–5 minutes to complete.

Your name (optional — leave blank to remain anonymous):

Providing your name allows us to follow up if you have unresolved concerns.

Date therapy concluded:

Treating therapist's name (if known):

Overall Experience

How would you rate your overall experience with Next Step Rehab?

⭐⭐⭐⭐⭐ Excellent — exceeded my expectations ⭐⭐⭐⭐ Very Good — met my expectations ⭐⭐⭐ Good — generally satisfactory ⭐⭐ Fair — some concerns ⭐ Poor — did not meet my expectations

Rate Your Care — Detailed Feedback

For each area below, please select the rating that best reflects your experience.
1 = Poor · 2 = Fair · 3 = Good · 4 = Very Good · 5 = Excellent

Area of Care	1 Poor	2 Fair	3 Good	4 Very Good	5 Excellent
Therapist's clinical skill and knowledge
Therapist's professionalism, respect, and courtesy
Clarity of explanation of my diagnosis and treatment plan
Therapist's responsiveness to my questions and concerns
Punctuality — therapist arrived at the scheduled time
Safety and comfort during in-home treatment sessions
Quality and clarity of my Home Exercise Program
Progress I made toward my personal therapy goals
Ease of scheduling appointments and administrative process
Overall quality of in-home therapy vs. clinic-based therapy

Your Experience in Your Own Words

What did you like MOST about your experience with Next Step Rehab?

What could we have done BETTER to improve your experience?

Is there anything else you would like us to know?

Would You Recommend Us?

✔ Yes — I would definitely recommend Next Step Rehab Maybe — depending on their specific needs Not at this time

Net Promoter Score (NPS): On a scale of 0–10, how likely are you to recommend Next Step Rehab to someone you know?

0–6= Not likely · 7–8= Neutral · 9–10= Very likely (Promoter)

Not at all likely (0) Extremely likely (10)

Testimonial Permission (Optional)

We love sharing patient success stories to encourage others who may benefit from in-home therapy. With your permission, we may share your comments on our website or marketing materials.

Written testimonial — share your experience in your own words (optional):

Permission to share your comments:

✔ Yes — you may share my comments anonymously (name withheld) ✔ Yes — you may share my comments with my first name and last initial ✗ No — please keep my comments private

Contact Preference

If you would like a member of our team to follow up regarding any aspect of your care or this survey, please provide your contact information below. This is completely optional.

I would like Next Step Rehab to follow up with me:

Yes — please call me Yes — please email me No follow-up needed

Phone number for follow-up:

Email address for follow-up:

Form 5b of 12 · Next Step Rehab Patient Intake Suite · www.nextstep-rehab.com