Please select the most appropriate answer. All responses are confidential.

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* 1. Today's Date

Date

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* 2. I am able to get the services I need from LFS.

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* 3. I am satisfied with services from LFS.

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* 4. My first appointment happened in a timely fashion.

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* 5. I am treated with dignity and respect at LFS.

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* 6. I feel welcome and safe at LFS.

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* 7. LFS staff is sensitive to my cultural needs.

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* 8. Services are provided in a language I understand.

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* 9. Services are provided at times & locations that are good for me.

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* 10. If I had other choices, I would still get services from LFS.

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* 11. I would recommend LFS to a friend or family member.

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* 12. LFS staff is sensitive to any trauma experienced in my life.

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* 13. Because of LFS services, my life has improved.

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* 14. Because of LFS services, I am better able to handle things when they go wrong.

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* 15. Because of LFS services, I’m better able to deal with a crisis.

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* 16. I set my service/treatment plan goals with the help of LFS staff.

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* 17. I feel comfortable asking questions about my services.

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* 18. In a crisis, I would have the support I need from family & friends.

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* 19. I was given information about my rights and responsibilities as a client.

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* 20. What do you appreciate most about LFS? (Optional)

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* 21. What would you like LFS to do differently? (Optional)

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* 22. What other services could LFS provide that would be helpful to you? (Optional)

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* 23. At which office location did you receive services?

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* 24. What general category of services did you receive?

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