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* 1. Date

Date

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* 2. Service Location

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* 3. Service

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* 4. The quality of professional and courteous service that I/my child currently receives from Primary Health Choice staff is:

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* 5. The level of courtesy and professionalism shown to me/my child by the Primary Health Choice staff is:

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* 6. My orientation to services that I/my child received from the Primary Health Choice staff was:

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* 7. My/my child's access to Primary Health Choice services, including after hours and emergencies is:

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* 8. The evaluation of my/my child's progress at Primary Health Choice is:

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* 9. The efficiency of Primary Health Choice staff in meeting my/my child's needs is:

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* 10. The quality of clinical/support services that I/my child receive at Primary Health Choice is:

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* 11. The effectiveness of clinical/support services that I/my child receive at Primary Health Choice is:

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* 12. The quality of services offered by Primary Health Choice are:

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* 13. Overall satisfaction with all services that have received at or by Primary Health Choice is:

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* 14. Has gainful employment been received for you or your child since receiving services from Primary Health Choice?

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* 15. Since receiving services from Primary Health Choice, have improvements been made in your/your child's social skills and relationships with family and friends?

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* 16. Since receiving services from Primary Health Choice do you find that you/your child has maintained support and abstinence from substances?

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* 17. The staff members of Primary Health Choice professional and courteous.

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* 18. The staff members of Primary Health Choice dress appropriately.

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* 19. The staff members of Primary Health Choice are timely with visits.

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* 20. Please list any strengths that you find are exhibited at Primary Health Choice.

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* 21. Please list any areas of improvement that could be made at Primary Health Choice.

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* 22. Have your child's school grades improved since entering the services of Primary Health Choice?

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* 23. Has your child experienced less school suspensions, bus suspensions, and/or expulsions since entering the services of Primary Health Choice?

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