What this feedback survey & review request does for home health agency owners and administrators
An editable Word + PDF template built for non-medical home care and home health agencies, care managers, and schedulers.
This template collects a five-question rating survey, open feedback, staff recognition, a public-review prompt with QR/link space, and a staff service-recovery box. Open it in Word or Google Docs, replace the bracketed placeholders with your name, logo, prices, and terms, and it's ready to use.
Online reviews are the biggest driver of new clients for a local business and the least systematic part of most operations. A short survey handed out or sent after the visit catches problems privately and gives you a natural moment to ask satisfied clients for a public review.
What is inside the template
- Five-to-eight question satisfaction survey with rating scales
- Open comment and 'what could we improve' fields
- Permission-to-contact and review request section
- Printable and digital versions with review-link placeholder
How to use it (step by step)
- Add your review link and decide how you will deliver the survey (paper at check-out, text link, email).
- Ask every client; consistency matters more than wording.
- Respond to negative feedback within a day; direct positive responders to the review link.
Common mistakes this template helps you avoid
- Asking only clients you expect to be happy.
- Not acting on the feedback, which staff notice quickly.
Expert tips from the field
- Track the average score monthly on the office wall.
- Quote real feedback in staff meetings; it changes behavior faster than instructions.
Why home health agency owners and administrators choose this over a generic template
Generic forms are written for nobody in particular. This one was written for home health and home care agencies: the fields, wording and clauses reflect real home health agency work such as a new client assessment visit for personal care or a post-hospital-discharge care start. It uses plain language clients can read, it has a header block for your logo and license number, and it matches the other Home Health Agency templates in the set so your intake, consent, policy and checklist documents look like one system.
Explore the full Home Health Agency template collection and paperwork guide, or see how it fits with the related documents below.
