* 1. Date survey completed

Date 
/
/
PLEASE TELL US HOW YOU FEEL ABOUT OUR SERVICE.
1 - Strongly Disagree .........................................5 - Strongly Agree

* 3. Participation… You participated in your child’s treatment.

* 4. Goals… The worker helped you to develop a specific plan that met your needs.

* 5. Relationship… You felt heard and respected by the worker.

* 6. Treatment… Your worker identified both strengths and problem areas in your family.

* 7. Culture… Your culture was respected and taken into consideration by the worker.

* 8. Family Centered Care… You and other family members were invited to participate in treatment as needed.

* 9. Communication… CFC staff seem to communicate well with each other and with you.

* 10. Outcome… You are more able to manage your problems than before treatment.

* 11. Information… You received information about other resources that was helpful.

* 12. Overall Care… You would recommend CFC to other families.

* 13. What do we do well?

* 14. What would improve our service for you?

* 15. Other Comments:

* 16. Would you like to speak with someone?

* 17. Contact me at:

T