Consumer Satisfaction Survey

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* 1. Date completed:

Date

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* 2. Please check which program location you are receiving services:

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* 3. Please check which program you are receiving services from:

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* 4. For Behavioral Health services, please select the program you are enrolled in:

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* 5. For Substances Use Disorder, please the program you are enrolled in:

Demographics:

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* 6. Gender:

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* 7. Age:

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* 8. Race/Ethnicity:

Survey Questions:

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* 9. Ease of Use:

Strongly Agree Agree Disagree Strongly Disagree Don't Know Does Not Apply
1. It is easy to make an appointment.
2. The Location of services is convenient.
3. I am able to get all of the services I think I need.
4. Services are available at times that are good for me.
5. Staff returns my calls within 24 hours.

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* 10. Quality of Care:

Strongly Agree Agree Disagree Strongly Disagree Don't Know Does Not Apply
6. I feel respected and listened to by staff.
7. I understand my treatment.
8. I feel comfortable asking questions about my treatment and/or medication.
9. I participate in my treatment planning.

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* 11. Outcomes:

Strongly Agree Agree Disagree Strongly Disagree Don't Know Does Not Apply
10. My symptoms are not bothering me as much.
11. I am achieving my goals.
12. I do better in daily life.

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* 12. Overall Satisfaction:

Strongly Agree Agree Disagree Strongly Disagree Don't Know Does Not Apply
13. I would recommend the services received at this agency to family and friends.
14. If I had other choices, I would still get services from this agency.
Thank you for telling us how we are doing!

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