Quality Home Health, Inc. - Referral Source Survey

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Referral Source Survey

Your referral is very important to us. Please take a few minutes to complete and submit this survey to help us address the needs of your patients.


1. Do you look for experience in a referral source? (check one):	Yes No Unimportant Extremely Important

2. What do you normally look for in a referral service	Familiarity Services Available Years of Service 24/7 Care Reputation Ease of Referral Specialized Services Other

3. How long have you been working with Quality Home Health?	< 1 year 2-4 years 5-10 years >10 years

4. Did you find the process of referring patients to Quality Home Health?	easy somewhat easy confusing difficult

5. Does Quality Home Health offer the services you find necssary for your patients needs?	Yes No Other

6. Do you understand what is needed for a substantial referral?	Yes No Unclear Would you like one of our referral forms? Yes No

7. How would you rate the reputation of Quality Home Health?	Poor Fair Good Excellent

8. What do you like best about Quality Home Health and our Services?

9.What do you like least about Quality Home Health and our Services?

10. Do you have any suggestions for Quality Home Health that would improve your service and possibly benefit others?

Thank you very much for your time and responses. It is our goal to continue to grow and excel in the services we offer. Of course, none of that is possible without your honest evaluation of the job we are doing.	Please check this box if you want to include your name. Name:

13. Would it be possible for Quality Home Health to use your answers, comments, and name for marketing and promotional materials in the future for website, and or print materials?	Yes No

14. Comments:

Quality Home Health | 519 N. Franklin St., Ste 203 | Morris, IL 60450
(815) 942-1256 | Fax (815) 942-5203

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