CSS Agency Satisfaction Survey Green

1.I liked the services I received here.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Don’t Know

Not Applicable

2.If I had other choices, I would still get
services from this agency.

3.I would recommend this agency to a
friend or family member.

4.The location of services was convenient
(parking, public transportation, distance,
etc.).

5.Staff was willing to see me as often as I
felt it was necessary.

7.Services were available at times that were
good for me.

10.Staff here believes that I can grow, change
and recover.

11.I felt comfortable asking questions about
my treatment and medication.

14.Staff encouraged me to take responsibility
for how I live my life.

16.Staff respected my wishes about who is,
and who is not, to be given information
about my treatment.

18.Staff were sensitive to my cultural/ethnic
background.

19.Staff helped me obtain the information I
needed so that I could take charge of
managing my illness.

20.I was encouraged to use consumer-run
programs (support groups, drop-in
centers, crisis phone line, etc.).

As a Direct Result of Services I received,

36.In a crisis, I would have the support I
need from family or friends.

38.Are you of Hispanic/Latino origin?

Yes

No

39.Race: Please mark one or all that you consider yourself to be: (Select All that Apply)

40.Please indicate your gender:

Male

Female

41.Team Name:

42.Case Manager:

43.Do you have additional comments?