Youth Satisfaction Survey

Survey for clients under 18 years old.

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* 1. Age:

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* 2. Grade:

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* 3. How long have you been coming to the Clinic

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* 4. Date

Date

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* 5. Please check the box which best describes how you feel:

  Strongly Agree Agree Neutral Disagree Strongly Disagree Does Not Apply
1. I am satisfied with my therapist.
2. My symptoms (like feeling sad, angry, tired...) don't bother me as much.
3. My problems (like getting into trouble, bad grades, stealing, tantrums...) are getting better.
4. I would recommend my therapist to family and friends.
5. I am doing better in school.
6. I believe my behavior is improving.
7. I get along better with my family members.
8. I am satisfied with my clinic doctor/nurse practitioner.
9. My clinic doctor/nurse practitioner tells me about my medications and possible side-effects in a way that I can understand.
10. I feel like I can ask my clinical doctor/nurse practitioner questions.
11. I would recommend my clinic doctor/nurse practitioner to family and friends.
12.I trust that the Clinic people will keep my personal information private.
13. The Front Office staff were friendly, courteous, and professional.
14. The Front Office Staff were helpful in scheduling my appointments.
15. I would recommend this clinic to my family, friends, and others.

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* 6. Please tell us all the services you receive at the Clinic:

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* 7. Comments or Suggestions:

Thank You!  Your responses help us build a better program!

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