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CLIENT SURVEY
Satisfaction Survey
Please fill this questionnaire out. Please only fill this survey out ONCE a month.
1.
What is your client ID#? (**PLEASE DO NOT ENTER YOUR NAME)
2.
What month are you filling this survey out for? (PLEASE only fill this out one time per month).
January
February
March
April
May
June
July
August
September
October
November
December
3.
Are you recently in need of coping skills to live in your current living environment?
Yes
No
Unsure
Prefer not to answer
4.
Have you recently received help from the staff at WSTC to gain coping skills for living in your current living environment? (Processing your situation in group, individual counseling, a referral to apply for a housing program, etc..)
Yes
No
Unsure
Prefer not to answer
5.
Do you have a transportation barrier (an issue with transporting yourself from point A to point B, perhaps because you have no gas money, no car, no license, no family to give rides, etc.)
Yes
No
Unsure
Prefer not to answer
6.
Have you recently received help from staff at WSTC to gain solutions for your transportation barriers (think processing your emotions in individual or group counseling, referrals to vocational navigator to help with work/school goals, think rides from REAL Team, rides from SABG, rides from Housing Case Manager, referrals for gas cards and or other community resources, being offered to do Telehealth if possible, bus passes).
Recently received a lot of support from WSTC for my transportation struggles.
Recently received some support from WSTC for my transportation struggles.
Recently received a little support from WSTC for my transportation struggles.
WSTC doesn't know I am struggling in this area (transportation issues).
WSTC knows I am struggling in this area (transportation issues) but I have not been helped yet in this area.
I prefer not to answer this question
7.
Do you have access to a clinical supervisor if you have asked?
Yes I have asked, and Yes I have been given access to have a conversation with a Clinical Supervisor.
Yes I have asked, and No I have not been given access to have a conversation with a Clinical Supervisor
No I have not asked, but I would like to speak to a Clinical Supervisor.
No I have not asked, because I do not need to speak to a Clinical Supervisor at this time.
I prefer not to answer this question.
8.
Do you believe that your PHYSICAL HEALTH has improved since you joined us at WSTC? (This is your body)
Yes, since joining WSTC I have been able to tend more to my physical body/receive the support I need so my physical health has improved.
No, no change in physical health has been noticed.
Unsure, I am unsure if my physical health has improved since beginning treatment at WSTC.
I prefer not to answer this question
9.
Do you believe that your MENTAL/EMOTIONAL HEALTH has improved since you joined us at WSTC? (This is your mind and your thoughts and emotions)
Yes, since joining WSTC I have been able to tend more to my mind, thoughts, emotions, so my mental health has improved.
No, no change in mental health has been noticed.
Unsure, I am unsure if my mental health has improved since beginning treatment at WSTC.
I prefer not to answer this question
10.
Do you believe you are more likely to prevent a future relapse than you were in the past?
Yes, I believe since joining treatment at WSTC I have learned some coping skills to help me prevent a relapse in the future (such as Seeking Safety, choosing healthy people to engage with, building up a support network, knowing my triggers, working to build up my self esteem, getting help for the problems that keep me down, etc..)
No, I do not believe I have learned anything at WSTC to help me prevent a future relapse.
Unsure, I am unsure if I have learned anything to help prevent a future relapse.
I prefer not to answer this question.
11.
How do you feel about WSTC?
I feel satisfied with WSTC.
I feel somewhat satisfied with WSTC.
I feel somewhat dissatisfied with WSTC.
I feel dissatisfied with WSTC.
12.
Success. Please share the following information. If you would like to pass, please write in each box "I prefer not to say".
Share a recently POSITIVE day you have experienced. What did you experience on this day? How did it make an impact on your recovery? What gratitude did you feel on this day? To whom did you feel gratitude? How did your self esteem feel on this day?
Please share a day that you experienced that was a struggle but turned out OK. What were your triggers in the moments of darkness and how were you able to overcome your obstacles for an OK resolution?
The short story of your life, include pre-use, use, and where you are today (if no major changes have occurred between then and now please include what gives you hope in this moment).