CMFHP Survey


		We value your input and want to hear from you regarding how we are doing and how we may improve. Please send us your comments by filling out the form below.

		Your contact with Children's Mercy Family Health Partners was by:
		(choose all that apply)
			mail
			face-to-face with staff member
			presentation by staff member
			phone
			other

		The service and information you received was: (choose one)
			poor
			fair
			average
			good
			excellent

		Is there anything you would like us to change or improve about our service?


		Name of staff member who helped you:


		Other comments or concerns you would like us to hear:


		Name of person completing this survey (optional):


		Phone number and/or email (optional)