Family / Survivor Perception of Bereavement Services

Family/Survivor Perception of Bereavement Services Survey

Thank you for allowing us to provide hospice services to your family. We are interested in your ideas or opinions about our program. Please take a moment to answer the following questions. If you need assistance in completing this form, please feel free to contact our office at +1(951) 808-3060.

For questions 1-5, please choose the appropriate number that best describes your opinion.

1 - Strongly Agree 2 - Agree 3 - Disagree
4 - Strongly Disagree 5 - No Opinion or N/A

Date

6. Suggestions for improvements/additional comments:

7. What most impressed us about the hospice care/services was?

We would like to discuss our responses further.YesNo

Name (Optional)

Thank you for your valuable feedback. This confidential information will be used only in efforts to improve care/services.