For each item, mark the response that best answers the question "Am I Satisfied?".

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* Name (OPTIONAL)

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* Today's Date

Date

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* Sex

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* What is your age?

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* Time In Service

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* SERVICES

  Strongly Disagree Disagree Neutral Agree Strongly Agree N/A
17. I like the services that I receive from this organization.
18. I feel like I have a say in my treatment.
19. Staff have helped me set goals for myself.
20. I receive the kinds of services that I want and need.
21. Staff returned my calls.
22. Services were available at times that were good for me.
23. Staff believe that I can grow, change and recover.
24. I feel comfortable asking questions about the services, treatment or medication.
25. I feel free to complain when I am not satisfied.
26. I was given information about my rights.
27. Staff respect my wishes about confidentiality.
28. Staff help me obtain information I need concerning my recovery.
29. My counselors listen to what I have to say.
30. My counselors help me to set goals for myself.
31. I participate in my treatment planning.
32. IF I was taking medication, staff told me what side effects to watch out for.
33. I am satisfied with the medication services I am receiving (or have received)
34. I believe that the medication I taking is effective and helping me.
35. I deal more effectively with daily problems.
36. I am better able to control my life.
37. I am better able to deal with crisis.
38. Staff have respected my wishes about who is, and who is not, to be given information about my treatment and/or services.
39. Staff are sensitive to my cultural / ethnic background (race, religion, language, etc.)
40. I am getting along better with my family.
41. I do better in social situations.
42. I do better in school and/or work.
43. My problems are not bothering me as much.
44. I feel I am coping with life better.
45. I am involved in my community (for example, Church, volunteering, sports, support groups, work, etc.)
46. I can have the life I want, despite my disease/disorder.
47. I feel like I am in control of my treatment.
48. My wishes are respected about the amount of family involvement I want in my treatment.
49. I give back to my family and/or community.
50. The services I receive are helping to resolve my problem(s).
51. I would recommend this organization to a friend or a family member.
52. Overall, I am satisfied with these services

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* Please tell us in your own words what we could do to improve the clinic's services.

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