Consumer Questionnaire

Thank you for taking the time to complete this questionnaire. It is very important for us to get this important information from you, so we can improve how we provide services in our community. We value you and your opinion.

* Your name (optional):

* Your provider's name (optional):

* Please help us improve our services by answering the following questions about the services you received. Please indicate if you Strongly Disagree, Disagree, are Undecided, Agree or Strongly Agree with each of the statements below.

  Strongly Disagree Disagree Undecided Agree Strongly Agree
1. Overall, I am satisfied with the services my child received
2. I helped to choose my child's services.
3. I helped to choose my child's treatment goals.
4. The people helping my child have stuck with us no matter what.
5. I felt my child had someone to talk to when he or she was troubled.
6. I participated in my child's treatment.
7. The services my child and/or family received were right for us.
8. The location of services was convenient for us.
9. Services were available at times that were convenient for us.
10. My family got the help we wanted for my child.
11. My family got as much help as we needed for my child.
12. Staff treated me with respect.
13. Staff respected my family’s religious/spiritual beliefs.
14. Staff spoke with me in a way that I understood.
15. Staff were sensitive to my family's cultural/ethnic background.
16. Office staff were helpful, respectful, and friendly.
17. Business Office/Billing staff were helpful, respectful, and friendly.

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