Client Entrance Survey

Please help our agency make services better by answering some questions about the services you received. Your answers are confidential and will not influence the services you receive. Put a cross (X) in the box that best describes your answer. Thank you!!!

	Strongly Disagree	Disagree	Undecided	Agree	Strongly Agree
I am satisfied with the referral process	I am satisfied with the referral process Strongly Disagree	I am satisfied with the referral process Disagree	I am satisfied with the referral process Undecided	I am satisfied with the referral process Agree	I am satisfied with the referral process Strongly Agree
It was easy to find the facility.	It was easy to find the facility. Strongly Disagree	It was easy to find the facility. Disagree	It was easy to find the facility. Undecided	It was easy to find the facility. Agree	It was easy to find the facility. Strongly Agree
The staff did a good job in reference to customer service.	The staff did a good job in reference to customer service. Strongly Disagree	The staff did a good job in reference to customer service. Disagree	The staff did a good job in reference to customer service. Undecided	The staff did a good job in reference to customer service. Agree	The staff did a good job in reference to customer service. Strongly Agree
I received feedback from staff regarding services quickly	I received feedback from staff regarding services quickly Strongly Disagree	I received feedback from staff regarding services quickly Disagree	I received feedback from staff regarding services quickly Undecided	I received feedback from staff regarding services quickly Agree	I received feedback from staff regarding services quickly Strongly Agree
All of my questions were answered during intake.	All of my questions were answered during intake. Strongly Disagree	All of my questions were answered during intake. Disagree	All of my questions were answered during intake. Undecided	All of my questions were answered during intake. Agree	All of my questions were answered during intake. Strongly Agree
I feel safe in the environment	I feel safe in the environment Strongly Disagree	I feel safe in the environment Disagree	I feel safe in the environment Undecided	I feel safe in the environment Agree	I feel safe in the environment Strongly Agree
I am likely to recommend your organization to someone needing services.	I am likely to recommend your organization to someone needing services. Strongly Disagree	I am likely to recommend your organization to someone needing services. Disagree	I am likely to recommend your organization to someone needing services. Undecided	I am likely to recommend your organization to someone needing services. Agree	I am likely to recommend your organization to someone needing services. Strongly Agree
I have been treated with dignity and respect.	I have been treated with dignity and respect. Strongly Disagree	I have been treated with dignity and respect. Disagree	I have been treated with dignity and respect. Undecided	I have been treated with dignity and respect. Agree	I have been treated with dignity and respect. Strongly Agree
I am satisfied with the program orientation.	I am satisfied with the program orientation. Strongly Disagree	I am satisfied with the program orientation. Disagree	I am satisfied with the program orientation. Undecided	I am satisfied with the program orientation. Agree	I am satisfied with the program orientation. Strongly Agree
My expectations in reference to admission were fully met.	My expectations in reference to admission were fully met. Strongly Disagree	My expectations in reference to admission were fully met. Disagree	My expectations in reference to admission were fully met. Undecided	My expectations in reference to admission were fully met. Agree	My expectations in reference to admission were fully met. Strongly Agree

Strongly Disagree

Disagree

Undecided

Agree

Strongly Agree

I am satisfied with the referral process

I am satisfied with the referral process Strongly Disagree

I am satisfied with the referral process Disagree

I am satisfied with the referral process Undecided

I am satisfied with the referral process Agree

I am satisfied with the referral process Strongly Agree

It was easy to find the facility.

It was easy to find the facility. Strongly Disagree

It was easy to find the facility. Disagree

It was easy to find the facility. Undecided

It was easy to find the facility. Agree

It was easy to find the facility. Strongly Agree

The staff did a good job in reference to customer service.

The staff did a good job in reference to customer service. Strongly Disagree

The staff did a good job in reference to customer service. Disagree

The staff did a good job in reference to customer service. Undecided

The staff did a good job in reference to customer service. Agree

The staff did a good job in reference to customer service. Strongly Agree

I received feedback from staff regarding services quickly

I received feedback from staff regarding services quickly Strongly Disagree

I received feedback from staff regarding services quickly Disagree

I received feedback from staff regarding services quickly Undecided

I received feedback from staff regarding services quickly Agree

I received feedback from staff regarding services quickly Strongly Agree

All of my questions were answered during intake.

All of my questions were answered during intake. Strongly Disagree

All of my questions were answered during intake. Disagree

All of my questions were answered during intake. Undecided

All of my questions were answered during intake. Agree

All of my questions were answered during intake. Strongly Agree

I feel safe in the environment

I feel safe in the environment Strongly Disagree

I feel safe in the environment Disagree

I feel safe in the environment Undecided

I feel safe in the environment Agree

I feel safe in the environment Strongly Agree

I am likely to recommend your organization to someone needing services.

I am likely to recommend your organization to someone needing services. Strongly Disagree

I am likely to recommend your organization to someone needing services. Disagree

I am likely to recommend your organization to someone needing services. Undecided

I am likely to recommend your organization to someone needing services. Agree

I am likely to recommend your organization to someone needing services. Strongly Agree

I have been treated with dignity and respect.

I have been treated with dignity and respect. Strongly Disagree

I have been treated with dignity and respect. Disagree

I have been treated with dignity and respect. Undecided

I have been treated with dignity and respect. Agree

I have been treated with dignity and respect. Strongly Agree

I am satisfied with the program orientation.

I am satisfied with the program orientation. Strongly Disagree

I am satisfied with the program orientation. Disagree

I am satisfied with the program orientation. Undecided

I am satisfied with the program orientation. Agree

I am satisfied with the program orientation. Strongly Agree

My expectations in reference to admission were fully met.

My expectations in reference to admission were fully met. Strongly Disagree

My expectations in reference to admission were fully met. Disagree

My expectations in reference to admission were fully met. Undecided

My expectations in reference to admission were fully met. Agree

My expectations in reference to admission were fully met. Strongly Agree

Client Entrance Survey

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* 1. Location

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* 2. Admitted Program or Cancelled Appointment

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* 3. What is your gender?

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* 4. Which of the following categories best describes your employment status?

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* 5. Living Arrangements

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* 6. What is your age?

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* 7. Health Insurance

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* 8. Please choose the best answer to describe your experience.

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* 9. What has been the most helpful thing about the services you received during the assessment process?

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* 10. What would improve the services here?