Client Questionnaire Question Title * 1. Date survey completed Date Date Question Title * 2. Please indicate the service this survey pertains to: Brief Services: Walk-In Services CAMHP Counselling and Therapy: General counselling/therapy, School Based Mental Health Crisis Services: Mobile Crisis Family/Caregiver Skill Building: Triple P Intensive Treatment Services: Day Treatment, Intensive Supervision and Support Program , Family Intervention Support Program, Therapeutic Foster Care Specialized Consultation/Assessment Services: Eating Disorder Intervention, Trauma, Psychology, TAPP-C FRIENDS Anxiety Group Service Not Specified SNAP Group PLEASE TELL US HOW YOU FEEL ABOUT OUR SERVICE.1 - Strongly Disagree .........................................5 - Strongly Agree Question Title * 3. Participation… You participated in your child’s treatment. 1 2 3 4 5 Does not apply Question Title * 4. Goals… The worker helped you to develop a specific plan that met your needs. 1 2 3 4 5 Does not apply Question Title * 5. Relationship… You felt heard and respected by the worker. 1 2 3 4 5 Does not apply Question Title * 6. Treatment… Your worker identified both strengths and problem areas in your family. 1 2 3 4 5 Does not apply Question Title * 7. Culture… Your culture was respected and taken into consideration by the worker. 1 2 3 4 5 Does not apply Question Title * 8. Family Centered Care… You and other family members were invited to participate in treatment as needed. 1 2 3 4 5 Does not apply Question Title * 9. Communication… Compass staff seem to communicate well with each other and with you. 1 2 3 4 5 Does not apply Question Title * 10. Outcome… You are more able to manage your problems than before treatment. 1 2 3 4 5 Does not apply Question Title * 11. Information… You received information about other resources that was helpful. 1 2 3 4 5 Does not apply Question Title * 12. Overall Care… You would recommend Compass to other families. 1 2 3 4 5 Does not apply Question Title * 13. What do we do well? Question Title * 14. What would improve our service for you? Question Title * 15. Other Comments: Question Title * 16. Would you like to speak with someone? Yes No Question Title * 17. Contact me at: Done
