Consumer Satisfaction Survey

Therapy/Tutoring Services

25% of survey complete.

Thank you for answering this survey. It is used in part to evaluate staff and also make improvements in the program.

Question Title

* 1. Your Name (Optional)

Question Title

* 2. Most Recent Date of Service

Date of service

Date

Question Title

* 3. Clinician's Name or Department you were seen by

Question Title

* 4. Your Clinician or Department seen by

	Needs Improvement	Fair	Average	Very Good	Excellent	N/A
Staff knowledge and skills	Staff knowledge and skills Needs Improvement	Staff knowledge and skills Fair	Staff knowledge and skills Average	Staff knowledge and skills Very Good	Staff knowledge and skills Excellent	Staff knowledge and skills N/A
Staff listened and communicated well	Staff listened and communicated well Needs Improvement	Staff listened and communicated well Fair	Staff listened and communicated well Average	Staff listened and communicated well Very Good	Staff listened and communicated well Excellent	Staff listened and communicated well N/A
Staff considered my input	Staff considered my input Needs Improvement	Staff considered my input Fair	Staff considered my input Average	Staff considered my input Very Good	Staff considered my input Excellent	Staff considered my input N/A
Staff developed individualized treatment goals	Staff developed individualized treatment goals Needs Improvement	Staff developed individualized treatment goals Fair	Staff developed individualized treatment goals Average	Staff developed individualized treatment goals Very Good	Staff developed individualized treatment goals Excellent	Staff developed individualized treatment goals N/A
Progress made	Progress made Needs Improvement	Progress made Fair	Progress made Average	Progress made Very Good	Progress made Excellent	Progress made N/A
Recommendations and/or referrals, when needed	Recommendations and/or referrals, when needed Needs Improvement	Recommendations and/or referrals, when needed Fair	Recommendations and/or referrals, when needed Average	Recommendations and/or referrals, when needed Very Good	Recommendations and/or referrals, when needed Excellent	Recommendations and/or referrals, when needed N/A