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1. Date (Required.)

Date

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2. Service Location (Required.)

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3. Service (Required.)

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4. The quality of professional and courteous service that I/my child currently receives from Primary Health Choice staff is: (Required.)

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5. The level of courtesy and professionalism shown to me/my child by the Primary Health Choice staff is: (Required.)

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6. My orientation to services that I/my child received from the Primary Health Choice staff was: (Required.)

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7. My/my child's access to Primary Health Choice services, including after hours and emergencies is: (Required.)

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8. The evaluation of my/my child's progress at Primary Health Choice is: (Required.)

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9. The efficiency of Primary Health Choice staff in meeting my/my child's needs is: (Required.)

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10. The quality of clinical/support services that I/my child receive at Primary Health Choice is: (Required.)

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11. The effectiveness of clinical/support services that I/my child receive at Primary Health Choice is: (Required.)

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12. The quality of services offered by Primary Health Choice are: (Required.)

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13. Overall satisfaction with all services that have received at or by Primary Health Choice is: (Required.)

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14. Has gainful employment been received for you or your child since receiving services from Primary Health Choice? (Required.)

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15. Since receiving services from Primary Health Choice, have improvements been made in your/your child's social skills and relationships with family and friends? (Required.)

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16. Since receiving services from Primary Health Choice do you find that you/your child has maintained support and abstinence from substances? (Required.)

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17. The staff members of Primary Health Choice professional and courteous. (Required.)

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18. The staff members of Primary Health Choice dress appropriately. (Required.)

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19. The staff members of Primary Health Choice are timely with visits. (Required.)

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20. Please list any strengths that you find are exhibited at Primary Health Choice.

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21. Please list any areas of improvement that could be made at Primary Health Choice.

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22. Have your child's school grades improved since entering the services of Primary Health Choice? (Required.)

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23. Has your child experienced less school suspensions, bus suspensions, and/or expulsions since entering the services of Primary Health Choice? (Required.)

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