Student Health and Counseling Center - Patient Comment/Suggestion

Date: Time: AM/PM

Health Services
Acupuncture
Administrative Services/Executive Director's Office
Cashier
Chiropractic
Family PACT
Front Desk
Health Education
Lab

Medical Records
MDs & Nurse Practitioners
Nursing
Optometry
Pharmacy
Physical Therapy and Sports Rehabilitation
Screening
Triage
X-Ray

Counseling and Psychological Services
Front Desk
Group Session
Intake Evaluation
Ongoing Counseling
CAPS Screening

Name of staff member(s), if known:

Please rate the service you received at the area above today:

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Your comments and/or suggestions:

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Patient Comment/Suggestions