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In order to provide the best care possible, we’d like to know what you think about the services your child has received from our agency over the last 6 months. There are no right or wrong answers to the questions in this survey. Please indicate your agreement or disagreement with each of the following statements by circling the best response that represents your opinion. All responses will remain strictly confidential.

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* 1. Circle/Select the program you are providing feedback for:

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* 2. Overall, I am satisfied with the services my child received.

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* 3. I helped to choose my child’s services.

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* 4. I helped to choose the goals in my child’s service plan.

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* 5. The people helping my child stuck with us no matter what.

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* 6. I felt my child had someone to talk to when they were troubled.

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* 7. I participated in my child’s treatment/services.

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* 8. The services my child and/or family received were right for us.

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* 9. The location of services was convenient for us.

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* 10. Services were available at times that were convenient for us.

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* 11. My family got the help we wanted for my child.

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* 12. My family got as much help as we needed for my child.

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* 13. Staff treated me with respect.

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* 14. Staff respected my family's religious/spiritual beliefs.

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* 15. Staff spoke with me in a way that I understood.

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* 16. Staff were sensitive to my cultural/ethnic background (e.g., race, religion, language)

As a direct result of the services I received:

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* 17. My child is managing daily life.

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* 18. My child gets along with family members.

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* 19. My child gets along with friends and other people.

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* 20. My child is doing better in school and/or work.

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* 21. My child is able to cope when things go wrong.

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* 22. I am satisfied with our family life right now.

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* 23. My child is better able to do things they want to do.

As a result of the services my child and/or family

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* 24. I know people who will listen and understand me when I need to talk.

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* 25. I have people that I am comfortable talking with about my child’s problems.

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* 26. In a crisis, I would have the support I need from family or friends.

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* 27. I have people in my life who I enjoy doing things with.

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* 28. How long have you been receiving services?

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* 29. Which of the following best describes your ethnicity?

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* 30. Which of the following best describes your race?

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* 31. Sex assigned at birth

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* 32. Did someone assist you in completing this survey?

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* 33. Additional Comments

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* 34. Do you wish to be contacted to follow up on any of your survey responses?

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* 35. Contact Name:

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* 36. Contact Number:

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