Patient Feedback Form

Feedback Process

Northwest ADHD Treatment Center strives to provide excellent customer service and patient care. If you have feedback about any aspect of your experience, please complete the form below. Our management team will review and discuss your feedback. If you wish to have a member of our management team respond we will do so in written form within 30 days. Be aware that all information below will be shared with relevant management team members.

If your feedback relates to concerns of clinical practice, aspects of your chart may need to be reviewed. By completing this form, you agree to allow your clinical record to be reviewed by relevant members of the NW ADHD Management Team, if needed, to address the complaint. Please also be aware that for documentation purposes of complaints related to clinical practice, this form and any resolution strategies may be added to your clinical record. A summary of any resolution strategies will be added. The feedback and any resolution strategies will be kept as part of an administrative file.

By signing, you agree to the above process.

Name
First Last
Date
MM slash DD slash YYYY
Feedback summary
Consent
Please check here to indicate if you would like to be contacted by a member of our management team to inform you of any planned resolution strategies. A written notification of resolution strategies will be sent to you within 30 days.