International S.C.E.N.A.R. Technology Association

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FEEdback form On THERAPIST visit

Please note that your kind assistance in completing and sending this feed-back form will help everybody in the S.C.E.N.A.R. Community. Any information we receive will be shared with the practitioner concerned so that we can assist her or him to address any points you raise.

We normally do not reveal the name of the party providing the feedback, but will consider doing so where you specifically request it, or the situation demands.

Thank you for taking the time to complete and send the form below.

The feedback you provide will help improve the services offered by our trainer community. Your feedback will be shared with the trainer. Both the therapist-practitioner and ISTA welcome any feedback that will help improve your S.C.E.N.A.R. experience.

Please click on the relevant indicator against each question, (1) indicates the lowest mark, the least satisfaction with the coverage of the issue, (5) indicates the best, the greatest satisfaction. Feel free to identify yourself at the end of this form and / or to add any additional comments.

I would like to provide you with feedback on a visit to the following practitioner:

Name of the Practitioner
Date(s) of Consultation
Location of the Consultation
Duration	hours
Do you feel the practitioner listened to you and your needs?	v.poor neutral very good 1 2 3 4 5
Were you satisfied with the outcome of your consultation?	1 2 3 4 5
How did you find the ambience of the practice?	1 2 3 4 5
Was the treatment explained to you?	Yes No
Please comment further
If yes, how was the consultation?	1 2 3 4 5
Was enough time allocated to your treatment?	1 2 3 4 5
Overall, were you satisfied with this practitioner?	1 2 3 4 5
Had you been to see this practitioner before?	Yes No If yes, how often
Apart from this practitioner, how many others have you consulted in the last 12 months
What additional comments would you like make about this consultation?
What would you like to see changed in this practitioner's approach?
The following is optional, it would help to be able to talk more fully with you about any aspect of your feedack.
My name is
[required] My e-mail address is
My telephone number is

I would like it made known to the practitioner that this feedback was provided by me .

Thank you for your valuable time.

If you would like to tell us about your ill-health and how S.C.E.N.A.R. helped you, please provide your story via this general form.