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Feedback Form
Your Name
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First Name
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Your PT's name
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Please rate your PT on the following
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My PT communicated very well with me
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
My PT was well prepared for each session
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
My PT was knowledgeable
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
My PT was respectful
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
My PT made me feel heard
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
My PT addressed my goals
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
It felt like my PT genuinely cared
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I saw benefit in seeing my PT
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
What goals did you set with your PT?
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How involved did you feel with the goal setting process?
*
Did you feel like you achieved what you set out to with your PT? Please explain
*
In your opinion, what did your PT do well on?
*
In your opinion, what did you think the PT should improve on?
*
Was there anything else you wish your PT did or didn't do? Please explain
*
Would you recommend this PT to your friends or family?
*
Yes
No
How much would you pay for this PT per hour?
*
$90-$110/hour
$70-$90/hour
$50-$70/hour
$30-$50/hour
I wouldn't pay that much
Any additional feedback you'd like to leave for your PT?
Thank you!