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Client Satisfaction Survey v3
Help Us Improve
Your feedback helps Ireland Home Based Services know what we're doing well, and where we need to grow. Your honesty is appreciated and thank you for your time!
*
1.
My Initials (do not separate initials with periods or spaces)
(Required.)
*
2.
The first and last name of my IHBS Service Provider
(Required.)
*
3.
IHBS Case Number
(Required.)
*
4.
County of Residence
(Required.)
Bartholomew
Brown
Boone
Clark
Clay
Crawford
Daviess
Dearborn
Decatur
Dubois
Floyd
Gibson
Greene
Harrison
Hendricks
Jackson
Jefferson
Jennings
Johnson
Knox
Lawrence
Marion
Martin
Monroe
Montgomery
Morgan
Ohio
Orange
Owen
Parke
Perry
Pike
Posey
Putnam
Ripley
Scott
Shelby
Spencer
Sullivan
Switzerland
Vanderburgh
Vermillion
Vigo
Warrick
Washington
Other (please specify)
THIS IS NOT THE CORRECT SURVEY FOR CLIENTS IN THE COMMUNITY PARTNERS FOR CHILD SAFETY PROGRAM.
Access the correct survey for Community Partners for Child Safety cases
HERE.
*
5.
The service(s) this person provided to me and/or my family (choose all that apply):
(Required.)
Unknown
Parent Aide
Visitation
Home Based Casework
Fatherhood Engagement Services
Truancy Termination
Home Based Therapy
Family Centered Treatment (FCT)
Trauma Focused Cognitive Behavioral Therapy
Family Preservation Services
Other (please specify)
6.
I want my feedback about my service provider to remain confidential.
Yes
No
7.
Your Age:
3-9
10-15
16-18
19-27
28-32
33-44
45-59
60 or over
