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1. Rate the services received from this provider

In order to provide the best possible services we would like to know what you think about the services you or your child received during the last six months. Please select the box that best describes your answer. There is space later in the survey to comment further or explain any of your answers. Your answers are confidential unless you choose to include your name.

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* 1. Overall, I am satisfied with the services my child received.

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* 2. I helped to choose my child's services.

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* 3. I helped to choose my child's treatment goals.

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* 4. The people helping my child stuck with us no matter what.

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* 5. I felt my child had someone to talk to when he/she was troubled.

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* 6. I participated in my child's treatment.

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* 7. The services my child and/or family received were right for us.

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* 8. The location of services was convenient for us.

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* 9. Services were available at times that were convenient for us.

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* 10. My family got the help we wanted for my child.

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* 11. My family got as much help as we needed for my child.

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* 12. Staff treated me with respect.

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* 13. Staff respected my family's religious/spiritual beliefs.

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* 14. Staff spoke with me in a way that I understood.

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* 15. Staff were sensitive to my cultural/ethnic background.

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