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* 1. Participant Type

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* 2. Please enter today's date

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* 3. About how long have you been in this program?

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* 4. How old are you?

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* 5. Gender

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* 6. Are you Hispanic or Latino/a?

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* 7. What is your race?

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* 8. What is the primary reason you are receiving services?

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* 9. Have you ever received services for this problem or a similar problem anywhere prior to coming here? (Check all that apply)

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* 10. Did you enter this program because a court judge, probation officer or parole officer required or told you to?

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* 11. Did someone from this program (your counselor, a doctor, nurse, or other therapist) discuss with you the use of medication(s) to assist in recovery? Which kind of medications? (Check all that apply)

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* 12. When you came for services, were you given information about your rights as a client?

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* 13. Have you been employed since you entered this program?

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* 14. Have you been enrolled in school since you entered this program?

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* 15. What do you think about the services you receive?

  Disagree Somewhat Agree Agree Strongly Agree
When I needed services right away, I was able to see someone as soon as I wanted.
This program helped me develop a plan for when I feel stressed, anxious, or unsafe.
The people I receive services from spend enough time with me.
I helped to develop my service/treatment goals.
The people I receive services from are sensitive to my cultural background (race, religion, language, sexual orientation, etc.)
I was given information about different services that were available to me.
I was given enough information to effectively handle my problems.
As a result of the program services I have received, I am less bothered by my symptoms.
As a result of the program services I have received, I am better able to cope when things go wrong.
As a result of the program services I have received, I am better able to accomplish the things I want to do.
As a result of the program services I have received, I am not likely to use alcohol and/or other drugs.
As a result of the program services I have received, I am doing better at work/school. (If this does not apply to you, please leave it blank.)
As a result of the program services I have received, I get along with my teachers/boss. (If this does not apply to you, please leave it blank.)
There is someone who cares about whether I am doing better.
I have someone who will help when I have a problem.
I have people in my life who are a positive influence.
The people I care about are supportive of my recovery.
People count on me to help them when they have a problem.
I have friends who are clean and sober.
I have someone who will listen to me when I need to talk.
Using alcohol and/or drugs is a problem for me.
I need to work on my problems with alcohol and/or drugs.
I would return to this program if I need help in the future.
I would recommend this program to a friend or family member.

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* 16. What is this program doing right?

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* 17. What could be done to improve this program?

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* 18. Is there anything else about this program that you would like to say?

0 of 18 answered
 

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