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* 1. Date on Exit Evaluation

Date / Time

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* 2. Which program did you participate in?

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* 3. Overall rating of services received?

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* 4. What I especially liked was:

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* 5. What I disliked was:

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* 6. Overall rating of care from clinicians/counselors/case managers:

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* 7. Care I especially liked were?

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* 8. Improvement is needed in?

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* 9. Overall rating of groups:

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* 10. Groups I especially liked were?

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* 11. Groups that need improvement are?

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* 12. Overall rating of Sitka Counseling facilities:

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* 13. I especially noticed?

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* 14. Name of your primary counselor? Name of person who completed intake/assessment?

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* 15. RECEPTION: Was the receptionist polite? Were they helpful? Did you receive the information and services you were seeking?

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* 16. INTAKE: Was the intake staff polite and helpful? Was the process made clear to you? Did you feel your questions were answered?

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* 17. FINANCE/BILLING: Were you adequately informed of your financial responsibility? Was the billing procedure explained to your satisfaction?

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* 18. COUNSELING: Was your counseling staff well informed about your mental health and substance abuse issues? Did you feel your counseling staff was attentive to your individual needs and concerns? Did he/she perform in a professional and responsible manner? Did he/she work with your family, employer, and any other persons who were involved in your treatment process? Did you feel you were adequately informed of what was expected of you?

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* 19. OTHER SESSIONS: Were the sessions interactive and thorough? Was the staff well informed? Did you feel your questions were answered?

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* 20. Number of months you received services at Sitka Counseling?

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* 21. Did the court system or an attorney refer you?

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* 22. If no to above question, who referred you?

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* 23. Do you feel you benefited from the services you received? Why or why not?

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* 24. How do you plan to maintain your recovery proram?

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* 25. Other Comments:

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