Client Satisfaction Survey 21

Question Title

* 1. Program/ Location (Please select only one program, per survey. If you receive services from multiple programs, please complete separate surveys for each program):

Question Title

* 2. Provider Name:

Please mark the box that best represents your response to each statement.

Question Title

* 3. I was able to access services at a time and location that met my needs.

Strongly agree

Agree

Disagree

Strongly disagree

N/A

Question Title

* 4. My service provider(s)/ care team actively partners with me in order to create/ modify my treatment plan goals and ensure that I am valued client.

Strongly agree

Agree

Disagree

Strongly disagree

N/A

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* 5. I will use the knowledge and resources provided to continue working toward my goals (if not already met).

Strongly agree

Agree

Disagree

Strongly disagree

N/A

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* 6. If a family member, or friend needed similar services, you would recommend CMMHC.

Strongly agree

Agree

Disagree

Strongly disagree

N/A

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* 7. If financial assistance was needed, you received the necessary financial information to apply for assistance.

Strongly agree

Agree

Disagree

Strongly disagree

N/A

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* 8. If a problem did arise during the course of treatment, it was addressed by your provider(s)/ care team?

Strongly agree

Agree

Disagree

Strongly disagree

N/A

Question Title

* 9. Staff treated me with respect and were sensitive to my:

	Strongly agree	Agree	Disagree	Strongly disagree	N/A
Cultural needs	Cultural needs Strongly agree	Cultural needs Agree	Cultural needs Disagree	Cultural needs Strongly disagree	Cultural needs N/A
Ethnic needs	Ethnic needs Strongly agree	Ethnic needs Agree	Ethnic needs Disagree	Ethnic needs Strongly disagree	Ethnic needs N/A
Spiritual needs	Spiritual needs Strongly agree	Spiritual needs Agree	Spiritual needs Disagree	Spiritual needs Strongly disagree	Spiritual needs N/A
Gender needs	Gender needs Strongly agree	Gender needs Agree	Gender needs Disagree	Gender needs Strongly disagree	Gender needs N/A
Social needs	Social needs Strongly agree	Social needs Agree	Social needs Disagree	Social needs Strongly disagree	Social needs N/A

Question Title

* 10. In addition to my health care concerns, I was offered assistance (if needed) with:

	Strongly agree	Agree	Disagree	Strongly disagree	N/A
Employment	Employment Strongly agree	Employment Agree	Employment Disagree	Employment Strongly disagree	Employment N/A
Education	Education Strongly agree	Education Agree	Education Disagree	Education Strongly disagree	Education N/A
Housing	Housing Strongly agree	Housing Agree	Housing Disagree	Housing Strongly disagree	Housing N/A
Transportation	Transportation Strongly agree	Transportation Agree	Transportation Disagree	Transportation Strongly disagree	Transportation N/A

Question Title

* 11. If you didn't access CMMHC services, what would you have done instead?

	Strongly agree	Agree	Disagree	Strongly disagree	N/A
Seek assistance from family/ friends	Seek assistance from family/ friends Strongly agree	Seek assistance from family/ friends Agree	Seek assistance from family/ friends Disagree	Seek assistance from family/ friends Strongly disagree	Seek assistance from family/ friends N/A
Seek alternative care/ went to the hospital	Seek alternative care/ went to the hospital Strongly agree	Seek alternative care/ went to the hospital Agree	Seek alternative care/ went to the hospital Disagree	Seek alternative care/ went to the hospital Strongly disagree	Seek alternative care/ went to the hospital N/A
Be in trouble with law enforcement/ legal issues	Be in trouble with law enforcement/ legal issues Strongly agree	Be in trouble with law enforcement/ legal issues Agree	Be in trouble with law enforcement/ legal issues Disagree	Be in trouble with law enforcement/ legal issues Strongly disagree	Be in trouble with law enforcement/ legal issues N/A
Continued Drinking/ Using Drugs	Continued Drinking/ Using Drugs Strongly agree	Continued Drinking/ Using Drugs Agree	Continued Drinking/ Using Drugs Disagree	Continued Drinking/ Using Drugs Strongly disagree	Continued Drinking/ Using Drugs N/A
Nothing	Nothing Strongly agree	Nothing Agree	Nothing Disagree	Nothing Strongly disagree	Nothing N/A

Client Satisfaction Survey 21

Question Title

* 1. Program/ Location (Please select only one program, per survey. If you receive services from multiple programs, please complete separate surveys for each program):

Question Title

* 2. Provider Name:

Question Title

* 3. I was able to access services at a time and location that met my needs.

Question Title

* 4. My service provider(s)/ care team actively partners with me in order to create/ modify my treatment plan goals and ensure that I am valued client.

Question Title

* 5. I will use the knowledge and resources provided to continue working toward my goals (if not already met).

Question Title

* 6. If a family member, or friend needed similar services, you would recommend CMMHC.

Question Title

* 7. If financial assistance was needed, you received the necessary financial information to apply for assistance.

Question Title

* 8. If a problem did arise during the course of treatment, it was addressed by your provider(s)/ care team?

Question Title

* 9. Staff treated me with respect and were sensitive to my:

Question Title

* 10. In addition to my health care concerns, I was offered assistance (if needed) with:

Question Title

* 11. If you didn't access CMMHC services, what would you have done instead?

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* 12. What did you find most helpful about the service(s) you received from CMMHC?

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* 13. Do you have any additional comments, and/or would you like to tell us about your experience at CMMHC?