Client Survey Form

Cultural Information: *

Race/Ethnicity

Age

Gender

Time in program

Optional Information:

Name

Completed Survey with

Access/Admission/Orientation

I was admitted to the program in a reasonable amount of time. *

If there was a Waiting List, appropriate contact was made to me so that admittance into the program occurred seamlessly. *

The staff who admitted and oriented me to available services were knowledgeable and professional. *

I reviewed and was provided a Handbook (Guide to Services) that explained the program rules, program limitations, as well as financial responsibilities including billing, no show policy, and insurance information. *

The Mission, Values, and Goals of the Program were explained to me. *

Referrals, Transition and/or Discharge

I was provided with relevant community referrals when I asked for them or as the staff became aware of my need.*

If a level of care change or other type of Transition occurred, I was informed and participated in this change.*

Upon Discharge, I was consulted and participated in reviewing my progress.*

Upon Discharge, the need or availability for additional services was discussed with me.*

Upon Discharge, I was provided with a copy of my Discharge Summary.*

After Discharge, follow up contact was performed within 30 days.*

Input from Persons Served

People who work here seem interested in my progress and services provided.*

I am encouraged to give my opinion about my treatment, the staff, as well as the program and services.*

There are several different ways to offer feedback about the program (suggestion box, satisfaction survey, online survey, etc.).*

I understand how my opinion is used to improve business practices including the program and services.*

Rights and Responsibilities

I am treated with dignity and respect.*

My rights and responsibilities were clearly explained to me and I was offered a copy for my records.*

If something happens that I don’t like or I feel like my rights have been violated, I know how to file a complaint or a grievance.*

Duty to Warn and Limits to Confidentiality were explained to me.*

My rights regarding privacy and confidentiality was explained to me.*

The Assessment Process

My needs were identified and discussed with an educated and respectful staff member.*

I felt heard, listened to, and safe when disclosing my reasons for seeking services.*

I understand why I am asked questions about my history, goals, and preferences.*

I felt respected when sharing my history and developing a plan for services.*

Treatment Planning

I participated in the development of my treatment plan.*

I have a copy of my treatment plan or was offered a copy.*

I signed and reviewed my treatment goals and objectives on a regular basis.*

My treatment plan is revised or updated when things change or at my request.*

Quality of Care

I would recommend the services I was provided to my family and friends.*

The staff seem educated and competent when providing care.*

The staff discussed with me and provided me with relevant and current therapeutic interventions while I was receiving services.*

The environment and energy of the facility felt welcoming, professional, private, and safe.*

I am encouraged to include family and/or my other support systems when engaging in services.*

Quality of Life

My overall Quality of Life has improved since beginning services.*

I am doing better in school, work, and/or other daily activities.*

My personal relationships, family relationships, and/or support system dynamic has improved.*

My social interaction is healthier and I feel more confident with my life situations.*

I am more self-aware and better at managing my Mental Health needs.*

Cultural Competency

My religious or spiritual beliefs and/or practices are respected.*

The staff has a professional understanding of my educational, social, socioeconomic, and family background.*

I can easily understand the staff when they are speaking to me.*

Other Complementary Health Approaches such as Yoga, Nutrition Management, Chiropractic Care, Acupuncture, Exercise, and Meditation were discussed.*

The staff seemed self-aware, displayed an open attitude including knowledge and skills, and appeared open toward others.*

Accessibility and Technology

The building and location are easily accessible for my needs.*

My request for Reasonable Accommodations was taken seriously and met my needs.*

Utilizing community transportation to and from my appointments fit my needs.*

Utilizing available Technology Systems such as the client portal to submit or access relevant medical information was simple and straightforward.*

Telehealth Services were simple to understand and use.*

Technology support was available to me if there were technology system issues.*

Using the Phone System including Voicemail or ability to contact staff was simple and current with common technology standards.*

Searching the website for location, contact information, services available, hours of operation, or performance outcome measures was easily accessible.*

Health and Safety

The organization provides services in a safe setting.*

Services are provided in a clean and sanitary facility.*

I feel safe in the neighborhood and parking areas around the business location.*

I believe the organization values my personal health and safety by implementing policies that do NOT permit weapons, tobacco, alcohol, and other illicit or illegal drugs on the premises, at agency sponsored events, or on agency owned property.*

In the event of an emergency while receiving services or while at the facility, I can access health and safety information for safe evacuation or other emergency situations.*

Comments and Feedback

What do we do best?

What is the one area we could most improve?

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