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Please help our agency make services better by answering some questions. Your answers are confidential and will not influence current or future services you receive. 

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* 1. Who is completing this survey?

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* 2. In what program are you receiving services?

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* 3. Are you receiving services in any additional Programs with this agency?

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* 4. Are you receiving services in any additional programs with this agency?

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* 5. How long have you been receiving services with this agency?

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* 6. Are you discharging or will you continue with services?

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* 7. Race: How do you identify?

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* 8. Gender: How do you identify?

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* 9. What is your age?

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* 10. I am satisfied with the services I have received.

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* 11. If I had other choices, I would still choose to get services from this agency.

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* 12. I would recommend this agency to a friend or family member.

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* 13. I am treated with dignity and respect.

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* 14. Staff are sensitive to my cultural background (race, religion, language, etc.).

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* 15. I participated in the development of my treatment plan.

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