Question Title

* 1. What program are you receiving services in?

Question Title

* 2. This is a confidential and private place.

Question Title

* 3. The care provider is helpful and listens to my concerns.

Question Title

* 4. I feel comfortable sharing treatment concerns with my care provider.

Question Title

* 5. Treatment/counseling is focused on achieving my goals and fits my needs.

Question Title

* 6. The care provider explains things in a way I understand.

Question Title

* 7. I am treated with respect by all staff.

Question Title

* 8. The office staff answer my questions and help if there is a problem.

Question Title

* 9. Would you recommend our agency to friends and family?

Question Title

* 10. Who sent you here for services?

Question Title

* 11. Optional:  Name of Care Provider

Question Title

* 12. Optional: Comments and feedback

Question Title

* 13. What is your age?

Question Title

* 14. What is your gender identification?

Question Title

* 15. Which race/ethnicity best describes you?

Question Title

* 16. The waiting room is comfortable and neat.

Question Title

* 17. I feel safe when I am in or around the building.

Question Title

* 18. Name - optional: (Due to COVID-19, please enter your name for our tracking purposes)

Question Title

* 19. My appointment today was in the following office:

T