For each item, mark the response that best answers the question "Am I Satisfied?".

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* Name (OPTIONAL)

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* Date:

Date

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* substance use recovery program

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* SERVICES

  Strongly Disagree Disagree Agree Strongly Agree N/A
1. I like the services that I receive from this organization.
2. I feel like I have a say in my treatment.
3. Staff have helped me set goals for myself.
4. I receive the kinds of services that I want and need.
5. Staff returned my calls.
6. Services were available at times that were good for me.
7. Staff believe that I can grow, change and recover.
8. I feel comfortable asking questions about the services, treatment or medication.
9. I feel free to complain when I am not satisfied.
10. I was given information about my rights.
11. Staff respect my wishes about confidentiality.
12. Staff help me obtain information I need concerning my recovery.
13. My counselors listen to what I have to say.
14. My counselors help me to set goals for myself.
15. I participate in my treatment planning.

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* SERVICES

  Strongly Disagree Disagree Agree Strongly Agree N/A
16. IF I was taking (prescription) medication, staff told me what side effects to watch out for.
17. I am satisfied with the (Prescription) medication services I am receiving (or have received)
18. I believe that the (Prescription) medication I am taking is effective and helping me.
19. I deal more effectively with daily problems.
20. I feel more comfortable with my life.
21. I am better able to deal with crisis.
22. Staff have respected my wishes about who is, and who is not, to be given information about my treatment and/or services.
23. Staff are sensitive to my cultural / ethnic background (race, religion, language, etc.)
24. I am getting along better with my family.
25. I do better in social situations.
26. I do better in school and/or work.
27. My problems are not bothering me as much.
28. I feel I am coping with life better.
29. I am involved in my community (for example, Church, volunteering, sports, support groups, work, etc.)
30. I can have the life I want, despite my illness.
31. I feel that I am key in determining the course of my treatment.
32. My wishes are respected about the amount of family involvement I want in my treatment.
33. I give back to my family and/or community.
34. The services I receive are helping to resolve my problem(s).
35. I would recommend this organization to a friend or a family member.
36. I found this survey easy to complete.

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* Comment:

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