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 (Required.)

Date

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What is your current status? (Required.)

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What is/was the program you are completing this survey for? (Required.)

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FACILITIES (Required.)

  😁Strongly Agree 🙂Agree 🙁Disagree 😠Strongly Disagree N/A
Facilities were easily located and accessible.
Facilities are neat and clean.
Facilities are well maintained.
Staff are polite and welcoming.

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SERVICES (Required.)

  😁Strongly Agree 🙂Agree 🙁Disagree 😠Strongly Disagree N/A
I like the services that I receive from this organization.
I feel like I have a say in my services.
Staff have helped me set goals for myself.
I receive the kinds of services that I want and need.
I feel comfortable asking questions about my services.
I feel free to complain when I am not satisfied.
I was given information about my rights.
Staff help me obtain information I need concerning my needs and benefits.
My case managers listen to what I have to say.
My case managers help me to set goals for myself.
I participate in my service planning.

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EFFECT OF SERVICES (Required.)

  😁Strongly Agree 🙂Agree 🙁Disagree 😠Strongly Disagree N/A
I deal more effectively with daily problems.
I am better able to control my life.
I am better able to deal with crisis.
Staff have respected my wishes about who is, and who is not, to be given information about my services.
Staff are sensitive to my cultural / ethnic background (race, religion, language, etc.)
I am getting along better with my family.
I do better in social situations.
I feel like I am in control of my services.
My wishes are respected about the amount of family involvement I want in my services.
The services I receive are helping to resolve my problem(s).

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Financial Services (Required.)

  😁 Strongly Agree 🙂Agree 🙁Disagree 😠Strongly Disagree N/A
Staff were helpful regarding paying my bill (online options, payment plans, etc.)
Staff were helpful regarding collecting copays.
I was educated on financial options such as payment plans and/or charity care.
I understand my financial obligations for services.
I was routinely asked if my insurance information was up to date.

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EXPECTATIONS/EXPERIENCE (Required.)

  😁Strongly Agree 🙂Agree 🙁Disagree 😠Strongly Disagree N/A
The services I receive(d) met my expectations.
My overall experience with Westbrook has been/was positive.
I would refer family/friends to Westbrook Health.

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CARE COORDINATION
Care Coordination is responsible for actively organizing and managing your care. Your Care Coordinator facilitates communication between providers and community resources. (Required.)

  Strongly Agree Agree Disagree Strongly Disagree N/A
I am satisfied with the Care Coordination I receive.

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Comments:

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What programs are/were you enrolled in/participated in? (Check all that apply) (Required.)

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In what county did/do you receive services? (Required.)

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Did you receive any services via telehealth? (Required.)

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