Street Address

City, State, Zip

Phone Number

ARTERY THERAPEUTIC ARTS

Your Custom Text Here

1. Please enter your full name (first name & surname)

2. How did you hear about my service?

3. What prompted you to choose my service?

4. Please describe your experience after the sessions. What benefits did you gain?

5. What can make the process better for you?

6. Is there anything else you would like to add?

7. How likely are you to recommend my art therapy sessions to your friends / family / colleagues?

Please choose ONE option

Very likely

Likely

Unsure

Unlikely

Very unlikely

8. Would you like to be contacted to discuss your feedback?

Please choose ONE option

Yes

9. Can I use your answers in a testimonial?

Please choose ONE option

Yes

10. If your answer to Question 9 is 'Yes', please enter how you would like your name to appear.

For example: 1. First Name, Last Name 2. First Name, Last Initial 3. First Initial, Last Name 4. First Initial, Last Initial