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PA Organ and Tissue Donation Counseling Survey
What type of counseling did you receive?
(Required)
In Person
Telehealth
Combination of in-person and telehealth
How easy was it to schedule your first appointment?
(Required)
1 - Very difficult
2 - Somewhat difficult
3 - Somewhat easy
4 - Very easy
Why did you select the counselor? Please select all that apply.
(Required)
Counselor hours and availability
Location of office
Wished to see an in-person provider
Wished for telehealth counseling
Felt they would be a good fit after looking at their website
Felt their professional experience was a good match for my needs
Other - please comment:
Other reason
Did you continue counseling beyond the 8 sessions provided by the PA Organ and Tissue Donation Grief Counseling program?
(Required)
Yes
No
If yes, how did you pay for the sessions?
Private pay
Insurance
If no, why did you not continue?
Did not feel I needed additional sessions
Could not pay for additional sessions
Unsure
Other - please comment:
Other reason
Is there anything you would like to share with us about your experience with the Grief Counseling Program?
On a scale of 1-5, how satisfied were you with counseling services provided by your grief counselor?
(Required)
1 - Extremely Unsatisfied
2 - Unsatisfied
3 - Neutral
4 - Satisfied
5 - Extremely Satisfied
Please provide a comment for your score being lower than a 5.
Would you like someone from Gift of Life/CORE to follow up with you regarding your loved one’s donation?
(Required)
Yes
No
Name
First
Last
Phone
Email
Comments
This field is for validation purposes and should be left unchanged.