Date survey completed

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* 1. Date survey completed

Date 
PLEASE TELL US HOW YOU FEEL ABOUT OUR SERVICE.
1 - Strongly Disagree .........................................5 - Strongly Agree
Participation… You participated in your child’s treatment.

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

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

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

Relationship… You felt heard and respected by the worker.

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

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

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

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

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

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

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

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

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

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

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

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

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

Overall Care… You would recommend CFC to other families.

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

What do we do well?

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* 13. What do we do well?

What would improve our service for you?

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* 14. What would improve our service for you?

Other Comments:

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* 15. Other Comments:

Would you like to speak with someone?

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* 16. Would you like to speak with someone?

Contact me at:

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* 17. Contact me at:

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