Client Satisfaction Survey

Thank you for taking the time to tell us all about your experience with this agency/office. We appreciate your feedback on how satisfied or unsatisfied you are with the services that you are receiving. Your responses will be confidential and will never affect the services that you receive, however, the feedback that we get from clients/patients like you will help us identify strengths, weaknesses and make improvements to our agency/office. Thank you!

Question Title

* 1. How long have you been receiving assistance from this agency/office?

Less than 1 year

1–3 years

3-5 years

More than 5 years

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* 2. How was/is your experience with staff? Did Staff:

	Always	Most of the time	Sometimes	Rarely or never
Treat You with respect?	Treat You with respect? Always	Treat You with respect? Most of the time	Treat You with respect? Sometimes	Treat You with respect? Rarely or never
Seem to understand your situation and needs?	Seem to understand your situation and needs? Always	Seem to understand your situation and needs? Most of the time	Seem to understand your situation and needs? Sometimes	Seem to understand your situation and needs? Rarely or never
Do a good job of explaining the program requirements?	Do a good job of explaining the program requirements? Always	Do a good job of explaining the program requirements? Most of the time	Do a good job of explaining the program requirements? Sometimes	Do a good job of explaining the program requirements? Rarely or never
Respond in a timely manner?	Respond in a timely manner? Always	Respond in a timely manner? Most of the time	Respond in a timely manner? Sometimes	Respond in a timely manner? Rarely or never
Be sensitive to your ethnic and cultural background?	Be sensitive to your ethnic and cultural background? Always	Be sensitive to your ethnic and cultural background? Most of the time	Be sensitive to your ethnic and cultural background? Sometimes	Be sensitive to your ethnic and cultural background? Rarely or never
Show knowledge around available services?	Show knowledge around available services? Always	Show knowledge around available services? Most of the time	Show knowledge around available services? Sometimes	Show knowledge around available services? Rarely or never
Maintain your confidentiality?	Maintain your confidentiality? Always	Maintain your confidentiality? Most of the time	Maintain your confidentiality? Sometimes	Maintain your confidentiality? Rarely or never

Comment:

Question Title

* 3. What type of assistance do you /did you receive from this agency or program?

Housing Assistance

Health Insurance assistance

Food pantry

Care management or other social services assistance (SNAP, application assistance, Etc.)

Medical Care

Other type of assistance (please specify)

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* 4. Has assistance from this agency/office helped you to maintain or improve your situation?

Always

Most of the time

Sometimes

Not at all

Comment:

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* 5. Overall, how satisfied are you with the assistance you have received from this agency/office?

Very Satisfied

Somewhat satisfied

Somewhat dissatisfied

Very dissatisfied

Comment:

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* 6. How satisfied are you with your current Primary Care Physician and/or Speciality Doctors?

Very Satisfied

Somewhat Satisfied

Somewhat Dissatisfied

Very Dissatisfied

Comment:

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* 7. How likely are you to refer your family and/or friend to this agency/office?

Very likely

Somewhat Likely

Unlikely

Very unlikely

Comment:

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* 8. What did/do you like most about this agency/office?

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* 9. What do you think we can do to make this agency/office better?

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* 10. If you are HIV Positive and would like information on how to get assistance with food, rent and utility payments, payment of insurance premiums and copays, and other benefits such as SNAP food stamps, please provide your Name, Address and Phone number and one of our Community Health Workers will contact you.

THANK YOU FOR COMPLETING OUR SURVEY