* 1. Please indicate your affiliation with Capitol Care:

* 2. Please check the program(s) provided by Capitol Care that you are involved with:

* 3. Our agency's mission is to provide the highest quality of clinical services to promote the emotional and relational potential of all people served. We are committed to the core values of respect, responsiveness, innovation, and quality to enhance the unique experience of each individual at Capitol Care. Do you feel that our staff members demonstrate our mission on a regular basis?

* 4. Upon entering Capitol Care's facilities do you feel welcome?

* 5. All departments within our agency have a contact person; are you aware of whom your contact person is at Capitol Care?

* 6. When you contact our agency via telephone, is your call responded to appropriately and within 3-4 business days?

* 7. Do our transportation services meet your needs?

* 8. In comparison to other agencies, do you think our services and programs are creative?

* 9. Do you feel you have been included in the process of service for an individual we treat?

* 10. If you were referred to Capitol Care within the past year, how would you rate our intake process (on a scale of 1 to 5, with 5 being the best)?

* 11. Do you feel that the agency informs you of changes occurring in our services?

* 12. Capitol Care has various social/recreational functions; do you feel you are involved with knowing about these functions?

* 13. Do you feel that the individuals we serve have his/her needs met by the agency in a productive manner?

* 14. Do you see an improvement in the individual(s) we serve?

* 15. Do you feel that your input is valued by Capitol Care?

* 16. Do you have any further recommendations for our agency?

* 17. If you would like more information regarding our services, please provide us with your name and address so we can send you additional information.

* 18. Please identify any recommendations you have for our improvement of cultural diversity.

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