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154 Cannifton Road North, Belleville, K8N 4Z6
613 689 7783
Moss Psychology
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Emotionally Focused Therapy (EFT)
Eye Movement Desensitization and Reprocessing (EMDR)
COGMED
Contact Us
Get In Touch
Client Feedback
Home
About Us
F.A.Qs
Fees and Policies
Meet The Team
Resources
Cogmed
Psychologists of Ontario
Client Login
Free Mental Health Resources
Services
Online Services
In-Person Services
Clinical Supervision and Consultation
Adults
Children and Adolescents
Couples and Families
Seniors
Treatments
Cognitive Analytic Therapy (CAT)
Emotionally Focused Therapy (EFT)
Eye Movement Desensitization and Reprocessing (EMDR)
COGMED
Contact Us
Get In Touch
Client Feedback
Client Feedback
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Client Feedback
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Client Feedback
At Moss Psychology we are always striving to improve the services we offer. In helping us to do this we would be grateful if you could give us some feedback about your experience with our service. This questionnaire will only take around 5 minutes to complete. You do not have to answer every question, nor do you need to leave your name or any personally identifiable information, unless you want to. Thanks in anticipation for your help.
FACILITIES
(Required)
1 - Totally Unsatisfied
2
3
4
5 - Entirely Satisfied
How satisfied were you with the venue and facilities?
Was there anything you particularly liked, or did not like, about the venue?
Do you have any other comments about the venue?
The Services you received
This section asks about how well the services you received met your needs and helped you to achieve your goals. It also asks what you gained and what could be improved.
Which practitioner did you see?
(Required)
Dr. Andrew Moss
Sandra Ward
Regan Veillette
Emily Cheff-Lopez
Dimitri Dionisatos
I attended a group
To what extent did the service you received meet your needs?
(Required)
1 - Not at ALL
2
3
4
5
6
7
8
9
10 - Fully Met
To what extent did your work with the practitioner help you achieve your goals?
(Required)
1 - Not at ALL
2
3
4
5
6
7
8
9
10 - Fully Met
Do you have any suggestions for things that could have been done better?
Do you have any other comments about the service you received?
About You
This section asks for some details about you to help us understand how different kinds of people find the services we offer.
What is your age?
(Required)
I am aged 18 or under
I am aged 19 - 29
I am aged 30 – 49
I am aged 50 – 79
I am aged 80 or over
What is your gender?
(Required)
Male
Female
Non-binary / Trans
I do not wish to say
Other
How would you describe your sexuality?
(Required)
Straight (Heterosexual)
Gay/Lesbian (Homosexual)
Bisexual
I do not wish to say
Other
What is your ethnic group?
(Required)
White
First Nations / Inuit / Metis / Cree
Mixed / Multiple Ethnic Groups
Asian
Black / African / Caribbean
I do not wish to say
Other
About your feedback
Would you like us to get in touch with you about the feedback you have given?
(Required)
Yes
No
How would you like us to contact you?
(Required)
Phone
Email
Name
First
Last
Phone
(Required)
Email
(Required)
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