CSS - Youth 2011

1. Customer Satisfaction Survey- Youth

The Client Satisfaction Survey below is to improve substance abuse and mental health services that are delivered in Maine. Your responses to the questions on this survey will help us determine if changes are needed in the treatment delivery system that currently exists.

Your responses to this survey are completely confidential and will not be seen by this facility, nor does it identify you individually.

If you have any questions about this survey, please call 1-800-499-0027.

This survey is being conducted by the Office of Substance Abuse (OSA), Maine Department of Health and Human Services.

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* 1. What is the name of the facility where you received treatment services?

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* 2. What town is the facility in where you receive treatment?

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* 3. What is todays date?

Today

Date

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* 4. What is your age?

Your current age

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* 5. What is your gender?

Female

Male

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* 6. Are you of Hispanic/Latino origin?

Yes

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* 7. Which of the following best describes your race?

American Indian/Alaskan Native

Asian

Black/African American

Native Hawaiian/Pacific Islander

White

Bi-Racial

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* 8. What is your highest current educational level?

Less than high school graduate

High School graduate/GED

Some College

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* 9. How long have you been in THIS treatment program?

Less than 1 Month

1-3 Months

4-6 Months

7-12 Months

More than 1 year

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* 10. Are you being treated for a mental health problem? If so, where do you get most of your mental health treatment?

Yes, from the same agency I receive substance abuse treatment.

Yes, from a different agency than I receive substance abuse treatment.

I do not currently receive services for a mental health problem; however, I have in the past.

I do not have a mental health problem.