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Client/Person Served Satisfaction and Feedback on Clinical and Program Culturally Responsive Service

Fresno County Department of Behavioral Health (DBH) strives to provide culturally competent services that reflect the cultural and linguistic diversity of our community.  Please indicate your level of agreement with the statements below by checking the box to the right of the statement that best fits your opinion.  If a question does not apply to you, check N/A.  The information you provide is anonymous and will be kept confidential.

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* Date:

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* Name of Program (where you receive services):

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* Statement

  Strongly Disagree Disagree Neither Agree Nor Disagree Agree Strongly Agree N/A
1. The services I receive here help me achieve my goals (getting a job, going to school, taking care of family, having friends, etc.)
2. Staff collaborate with me about my treatment.
3. As a result of the services I receive here, I can handle my daily life better.
4. The services I receive here help me get along better with other people.
5. If I want to receive services from a person from my own racial or ethnic group, staff help me connect to those services.
6. There are interpreters easily available to assist me and/or my family.
7. If I want to receive services from a person of my own gender and/or from the LGBTQ+ community, staff help me connect to those services.
8. Staff provide alternative services to meet my cultural treatment needs.
9. Staff respect my religious or spiritual beliefs.
10. If I request, my family or friends are included in my services.
11. Staff have an understanding of the diversity within my racial or ethnic group.
12. Some of the treatment staff are from my racial or ethnic group.
13. Staff treat me with respect.
14. The facility has pictures or reading material that show people from my racial or ethnic group.
15. The waiting room has brochures or handouts that I can easily understand that tell me about services I can receive here.

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* Please complete the following information about yourself:

1. Age:

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* 2.  Ethnicity:  Are you Hispanic or Latino?

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* 2a).  If you are Hispanic or Latino, what is your ethnicity? (Check all that apply)

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* 3.  Race: (Check all that apply)

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* 4.  Primary Language Spoken at Home:

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* 5.  Sexual Orientation:

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* 6. Gender Assigned at Birth:

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* 7. Current Gender Identity:

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* 8.  Military/Service Involvement:

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* 9.  Disabilities:  Do you have a disability?  A disability is a physical or mental impairment or medical condition lasting at least six months that substantially limits major life activity, which is not the result of severe mental illness.

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* 10. Did you require language assistance to complete this survey?

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