COOPERATIVE COUNSELING SERVICES IIC CUSTOMER SATISFACTION SURVEY

1.Youth's Name  (optional):
2.Relationship of the person completing the form for the youth (include contact number if you would like a call back to discuss these responses further):(Required.)
3.Name of Behavioral Assistant (BA) or Clinician you are evaluating:(Required.)
4.I was contacted by the Clinician/BA within a week from the start of services to schedule the initial meeting.(Required.)
5.I was given a description of the services that were to be provided so that I had a full understanding of what the level of service entailed.(Required.)
6.I was involved in developing treatment goals for my child and felt the treatment goals were effectively addressed throughout services.(Required.)
7.The services were consistent throughout the course of treatment on the part of the Clinician/BA and in the case of tardiness or missed appointment, the Clinician/BA notified me and made the effort to reschedule the appointment.(Required.)
8.I felt that my child’s services were provided in a manner that was sensitive to my culture/cultural background.(Required.)
9.I felt services were helpful to my child and/or family.(Required.)
10.Please provide any additional feedback that you feel would be helpful for us to improve services.