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Please take a moment and let us know how we are doing.

If you are not a client of GCB, but have comments for us, feel free to use the comment box, but let us know how you are connected.

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* 1. Today's date

Date

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* 2. Which service(s) have you received recently?

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* 3. In the last month, how have you received services from the agency?

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* 4. Do you remember the names of the staff you have worked with when you received the service? (please write in any name(s) you recall)

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* 5. It helps us to know more about the people who receive our services.  Would you be willing to tell me your race and ethnicity?  

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* 6. Which county or area do you live in?

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* 7. How strongly do you agree with each statement? (some of these may not apply, if you have only received services by phone or video)

  Agree completely Agree somewhat Don't agree or disagree Disagree somewhat Disagree completely Not applicable
1. The lobby of the agency is clean and comfortable.
2. The receptionist was courteous, respectful, and greeted me promptly.
3. The provider listed above responds to my calls appropriately.
4. I participate in planning my treatment.
5. My treatment is helping me reach my goals.
6. I'm satisfied with how often I see the provider listed above.
7. The provider listed above understands my needs.
8. Staff respects my religion, ethnicity, and sexual orientation / gender / gender identity.
9. The length of time it took to start treatment was reasonable.
10. If a friend needed help, I would refer them to this agency.
11. My overall satisfaction with the agency and staff is high.

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* 8. Please share any additional comments, including your contact information, if you would like a response:

Thank you for helping us improve our services!
Thank you!  You may give your completed survey to any GCB staff person,
or send it to:       Diane Wright, GCB, 1501 Madison Rd., Cincinnati, Ohio 45206

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