Customer Satisfaction Survey Template Question Title * 1. Treatment You Received/Provider Name Clinician/Counselor CBRS Peer Support Other OK Question Title * 2. What Services Did You Receive Counseling CBRS Peer Support SAP Evaluation Case Management OK Question Title * 3. I was treated with courtesy by the office staff Strongly Agree Somewhat Agree Agree Disagree Strongly Disagree Strongly Agree Somewhat Agree Agree Disagree Strongly Disagree Comments OK Question Title * 4. I was treated respectful by my provider Strongly Agree Somewhat Agree Agree Somewhat Disagree Strongly Disagree Strongly Agree Somewhat Agree Agree Somewhat Disagree Strongly Disagree Comment OK Question Title * 5. My treatment provider(s) helped me with my concern Strongly Agree Agree Disagree Strongly Disagree N/A Peer Support Peer Support Strongly Agree Peer Support Agree Peer Support Disagree Peer Support Strongly Disagree Peer Support N/A Counseling Counseling Strongly Agree Counseling Agree Counseling Disagree Counseling Strongly Disagree Counseling N/A CBRS CBRS Strongly Agree CBRS Agree CBRS Disagree CBRS Strongly Disagree CBRS N/A Comment OK Question Title * 6. I would recommend my provider to others Strongly Agree Somewhat Agree Agree Disagree Strongly Disagree Strongly Agree Somewhat Agree Agree Disagree Strongly Disagree Comments OK Question Title * 7. Please Indicate What Best Describes You Parent Child Guardian Receiving Counseling for Myself OK Question Title * 8. Do you have any other comments, questions, or concerns? OK DONE