Consumer Satisfaction Survey

We value your input and love to hear about your experiences with our services. Please fill out the following survey.

Date

Question Title

* Date

Date / Time
Person Completing The Survey

Question Title

* Person Completing The Survey

Age range of person receiving services

Question Title

* Age range of person receiving services

Services received at Crisis & Counseling Centers, which this survey refers to: (check only one) 

Question Title

* Services received at Crisis & Counseling Centers, which this survey refers to: (check only one) 

Location of Crisis Stabilization Unit (If Applicable)

Question Title

* Location of Crisis Stabilization Unit (If Applicable)

1. Please rate your satisfaction with how quickly you received services

Question Title

* 1. Please rate your satisfaction with how quickly you received services

2. Please rate whether you feel that you were treated in a welcoming and respectful manner

Question Title

* 2. Please rate whether you feel that you were treated in a welcoming and respectful manner

3. Please indicate whether the services you received focused on your primary concerns

Question Title

* 3. Please indicate whether the services you received focused on your primary concerns

4. Please rate whether you feel that the staff understood you and your situation

Question Title

* 4. Please rate whether you feel that the staff understood you and your situation

5. Please indicate how helpful the services you received were

Question Title

* 5. Please indicate how helpful the services you received were

6. Please indicate how comfortable the facilities were

Question Title

* 6. Please indicate how comfortable the facilities were

7. Please rate your overall experience

Question Title

* 7. Please rate your overall experience

8. How likely would you be to recommend our services to others

Question Title

* 8. How likely would you be to recommend our services to others

Additional Comments

Question Title

* Additional Comments

How did you hear about our services?

Question Title

* How did you hear about our services?

If you wish to be contacted, you may:
A) Write your clinician/case manager sfirst name and your appointment date and time
B) If you are leaving a CSU, enter your date of discharge, CSU location and initials. 
For confidentiality purposes, please DO NOT enter your name for any reason 

Question Title

* If you wish to be contacted, you may:
A) Write your clinician/case manager sfirst name and your appointment date and time
B) If you are leaving a CSU, enter your date of discharge, CSU location and initials. 
For confidentiality purposes, please DO NOT enter your name for any reason 

T