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Primary Health Choice, Inc.
Client Satisfaction Survey
*
1.
Date
(Required.)
Date / Time
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
*
2.
Service Location
(Required.)
Asheboro
Albemarle
Burlington
Clinton
Dunn
Elizabethtown
Fayetteville
Forest City
Gastonia
Greensboro
Greenville
Goldsboro
Jacksonville
Kenansville
Kinston
Laurinburg
Lenoir
Lexington
Lincolnton
Lumberton
Monroe
Pembroke
Raeford
Raleigh
Red Springs
Rockingham
Rocky Mount
Sanford
Shelby
Smithfield
St Pauls
Tarboro
Wadesboro
Whiteville
Wilson
Winston Salem
*
3.
Service
(Required.)
Community Support Team
Day Treatment
IIH
MH/SA TCM
NC Innovations Waiver
PSR
Psychiatric Services
TCM I/DD
Therapy
Other (please specify)
*
4.
The quality of professional and courteous service that I/my child currently receives from Primary Health Choice staff is:
(Required.)
Poor
Below Average
Average
Above Average
Excellent
*
5.
The level of courtesy and professionalism shown to me/my child by the Primary Health Choice staff is:
(Required.)
Poor
Below Average
Average
Above Average
Excellent
*
6.
My orientation to services that I/my child received from the Primary Health Choice staff was:
(Required.)
Poor
Below Average
Average
Above Average
Excellent
*
7.
My/my child's access to Primary Health Choice services, including after hours and emergencies is:
(Required.)
Poor
Below Average
Average
Above Average
Excellent
*
8.
The evaluation of my/my child's progress at Primary Health Choice is:
(Required.)
Poor
Below Average
Average
Above Average
Excellent
*
9.
The efficiency of Primary Health Choice staff in meeting my/my child's needs is:
(Required.)
Poor
Below Average
Average
Above Average
Excellent
*
10.
The quality of clinical/support services that I/my child receive at Primary Health Choice is:
(Required.)
Poor
Below Average
Average
Above Average
Excellent
*
11.
The effectiveness of clinical/support services that I/my child receive at Primary Health Choice is:
(Required.)
Poor
Below Average
Average
Above Average
Excellent
*
12.
The quality of services offered by Primary Health Choice are:
(Required.)
Poor
Below Average
Average
Above Average
Excellent
*
13.
Overall satisfaction with all services that have received at or by Primary Health Choice is:
(Required.)
Poor
Below Average
Average
Above Average
Excellent
*
14.
Has gainful employment been received for you or your child since receiving services from Primary Health Choice?
(Required.)
Yes
No
NA
*
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.)
Yes
No
*
16.
Since receiving services from Primary Health Choice do you find that you/your child has maintained support and abstinence from substances?
(Required.)
Yes
No
Does not apply
*
17.
The staff members of Primary Health Choice professional and courteous.
(Required.)
Yes
No
*
18.
The staff members of Primary Health Choice dress appropriately.
(Required.)
Yes
No
*
19.
The staff members of Primary Health Choice are timely with visits.
(Required.)
Yes
No
20.
Please list any strengths that you find are exhibited at Primary Health Choice.
21.
Please list any areas of improvement that could be made at Primary Health Choice.
*
22.
Have your child's school grades improved since entering the services of Primary Health Choice?
(Required.)
Yes
No
*
23.
Has your child experienced less school suspensions, bus suspensions, and/or expulsions since entering the services of Primary Health Choice?
(Required.)
Yes
No
