Must give a valid Provider/Service. 
No email address for a gift card only postal address.

A brief survey for Berks County residents with medical assistance, who go to a counselor, therapist, doctor, or community center for Mental health or addiction treatment.
You may skip questions, not all questions will apply.

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* Section 1) Provider and Service (ex. Haven Inpatient or Familicare Outpatient)

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* In general, is there anything negative or bad that you want to say about this service provider?

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* In general, is there anything positive or good that you want to say about this service provider?

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* Other services or providers you have (ex. SAM case manager, psychiatrist)

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* What is your age?

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* What is your gender?

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* What is your race?

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* What is your ethnicity?

Section 2) Service Access

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* Q2.1 In the last 12 months, did you or your child encounter any problems getting signed up for services with this provider?*

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* Q2.5 Have transportation problems ever been an issue for receiving services from this provider?

Section 3) Service Environment

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* Q3.1 Is the service environment safe and clean?

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* Q3.2 Do you feel your privacy/confidentiality is being respected by this provider?

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* Q3.3 Do you feel the staff understand and respect you with regard to cultural and personal experiences (gender, ethnicity, race, religion, sexuality)?

Section 4) Service Experience

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* Q4.3 In the last 12 months were you involved in making treatment decisions?*

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* Q4.4 Are your services with this provider helping you advance toward your goals?

If you or your child are under 21: 

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* Q4.7 Were family members involved in treatment planning decisions?

Section 5-6) Service Outcomes/Empowerment

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* Q5.1 Since this service began, my quality of life is:*

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* Q5.4 Did staff adequately explain your rights and responsibilities regarding your services or treatment?

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* Q5.6 Has this provider given you an anonymous means to express your opinions and concerns regarding your services?

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* Q5.7 If you could choose again, would you choose this provider for yourself?

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* Q6.6 Are you aware that there is a Complaint and Grievance Process you can use if necessary?

Section 8) Substance Use/Addiction - To help us better understand your experiences with substance use in the community, with your family, or even personally:

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* Q8.3 Addiction is a medical disease like diabetes, arthritis, or heart disease.

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* Q8.4 I would be embarrassed to tell people that someone close to me has a substance use disorder.

 
Neither agree nor disagree
Agree
Not applicable or prefer not to answer

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* Comments:

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* Gift card rules: To qualify, type your initials and a home address. No email. Must answer Q1 Where do you go for counseling, therapy, medication, or group support?

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