Question Title

* 1. Client Name

Question Title

* 2. Discharge Date

Date

Question Title

* 3. House/Unit/Module

Question Title

* 4. My living area was safe and comfortable.

Question Title

* 5. I had free time and recreation.

Question Title

* 6. The food was healthy.

Question Title

* 7. The food was good.

Question Title

* 8. I was allowed to have visits/phone calls with approved contacts.

Question Title

* 9. Living area staff treated me with respect.

Question Title

* 10. KidsPeace staff respected my culture (race, ethnicity, religion, and language).

Question Title

* 11. KidsPeace staff/foster parents respected my gender and sexual orientation.

Question Title

* 12. I was satisfied with my living area.

Question Title

* 13. My school was safe and secure.

Question Title

* 14. My school was clean, neat, and welcoming.

Question Title

* 15. I got help at school when I needed it.

Question Title

* 16. School staff respected my culture (race, ethnicity, religion, and language).

Question Title

* 17. School staff respected my gender and sexual orientation.

Question Title

* 18. I was satisfied with my school.

Question Title

* 19. I was involved in my treatment planning.

Question Title

* 20. If medication has been prescribed, I understand why it is important to take my medicine.

Question Title

* 21. My physical health was cared for.

Question Title

* 22. KidsPeace treatment providers (doctor, clinician, case manager, office staff, and nursing staff) respected my culture (race, ethnicity, religion, and language).

Question Title

* 23. KidsPeace treatment providers respected my gender and sexual orientation.

Question Title

* 24. My KidsPeace case manager helped me reach my goals.

Question Title

* 25. My KidsPeace doctor helped me reach my goals.

Question Title

* 26. My KidsPeace clinician helped me reach my goals.

Question Title

* 27. The groups I attended at KidsPeace helped me reach my goals.

Question Title

* 28. I understand the plan for my treatment after discharge.

Question Title

* 29. I am satisfied with the treatment services I received.

Question Title

* 30. What has been most helpful in your recovery process?

Question Title

* 31. Do you have any additional comments?

T