The Coleman Institute - Opiate and Narcotic Addiction, Substance Abuse Treatments, Detoxification Programs - Web Resources, Narcotics Anonymous, Al-Anon Family Group, ASAM, CoDependents Anonymous, SoberRecovery.com

Dear Patient or Support Person,

Please take a few minutes to complete and return this questionnaire to The Coleman Institute. Your responses are very important to us and help us to best meet your needs for compassionate, high quality care. Please answer the questions by circling each answer. We thank you for your feedback.

Patient Information

What type of service was performed?
	Detox	Naltrexone	Other
Where was your procedure performed?
	Richmond, VA	Cerritos, CA	La Mirada, CA	Kentucky
How did you hear about it?
	Former Patient	Internet	Ad	Other

Your Experience with us: Please evaluate the care you have received from us

	Excellent	Good	Fair	Poor	Unacceptable
1. Convenience of your scheduled procedure date and time
2. Ease of the pre-screening process/registration
3. Explanation/instructions given during the pre-screening
4. Professionalism of the front office staff
5. Wait time (first day appointment)
6. Experience with the Aftercare Coordinator
7. Did you find the Aftercare Coordinator helpful
8. Nurse’s explanation and service during your treatment
9. Physician’s explanation of your treatment
10. Physician’s knowledge about opiate addiction
11. Explanation of the Medical Discharge Instructions
12. Explanation of the Treatment Plan
13. Overall satisfaction with the care you have been provided
14. Your satisfaction with the effects of sedation
15. Would you recommend us to a friend/family member

Patient Impressions: If there is a staff member who you feel deserves special recognition please let us know their name so that we may commend their service from you:

Your Name:
Date of Service:	(mm/dd/yy)
Phone: