Our customers are very important to us and without your feedback we cannot expect to meet all of your needs.  Please take the time to fill out the following form.  It is not necessary to fill out all of the entries.  It is important that you tell us how you feel about our services and provide us with any input that will help us provide these services in a better manner.   This form is designed to be used by our customers and our employees.   If you would like a reply, please be sure to fill out the contact information at the bottom of this form.

What is your position?  Choose One Administrator/Executive Director Social Services DON Administration Nursing PHS Employee Other

What type of Facility?   Nursing Facility Assisted Living Facility Day Care or Other Day Program Home Health Other Choose One

What State?  Choose One Florida Georgia Missippi North Carolina Tennessee Virginia Maryland Washington DC

What type of services are being provided by Paradigm?  Choose One Psychiatry Only Psychology Only Both Psychiatry and Psychology Not Sure

How would you rate our service?

     Overall Choose One Excellent Good Fair Poor

     Is our program helpful to your residents?   Choose One Very Helpful Helpful but needs Improvement Not Sure Not Very Helpful

     Does our Paradigm Employee work well with other staff members?  Choose One Very Well Well Not very well Not well at all

We would appreciate any comments and ideas you may have regarding how we may be able to improve our services.

  Comments        

May we contact you?     yes   no 

if yes  please complete the following blocks.

      Your Name 

    A phone number where we may reach you during business hours or your email