Client Satisfaction Survey www.familiesfirstfl.com Question Title * 1. What services do you receive at Families First of Florida? Individual/Family counseling Targeted Case Management In-Home Parenting Psychiatry Substance Abuse treatment Other (please specify) Question Title * 2. Services are currently open. Yes, I am currently receiving services No, I have been discharged from services Question Title * 3. Which location do you receive your services from? Tampa Lakeland Orlando Ocala Tallahassee Panama City Question Title * 4. How are you related to the client? I am the client. I am the parent of the client. I am the legal guardian of the client. I am the client's case manager. I am the foster parent/caregiver for the client. Other (please specify) Question Title * 5. The gender of the person receiving services: Male Female N/A I would prefer not to answer Question Title * 6. The age group of person receiving services is: 12 years old or younger Over 12 years old but younger than 18 year old. Over 18 years old but younger than 22 years old. Over 22 years old. N/A I would prefer not to answer Question Title * 7. How long have services been received from Families First of Florida? less than 6 months. 6-12 months. more than 12 months. Other (please specify) Question Title * 8. Making the initial intake appointment was easy and scheduled timely. Yes Partially (either easy or timely but not both) No Don't know Please explain your answer. Question Title * 9. Overall, what is your satisfaction with the services you received? Extremely satisfied Moderately satisfied Slightly satisfied Neither satisfied nor dissatisfied Slightly dissatisfied Moderately dissatisfied Extremely dissatisfied Please explain your answer. Question Title * 10. Overall, how convenient was it for you to use Families First of Florida's services? Extremely convenient Very convenient Moderately convenient Slightly convenient Not at all convenient Please explain your score. Question Title * 11. I would recommend Families First of Floirda Yes - definitely! Most Likely Not Sure either way Probably not No - definitely not! Please explain Question Title * 12. I feel like the services provided by Families First of Florida have helped me. Greatly Agree Agree Neither Agree nor Disagree Disagree Greatly Disagree Greatly Agree Agree Neither Agree nor Disagree Disagree Greatly Disagree Please explain. Question Title * 13. Please share the name of your service provider (i.e. therapist, psychiatrist etc.) Question Title * 14. What else do you want us to know? Question Title * 15. Please complete the following if we can contact you: Name: Phone: Email: Done
