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* 1. Which program are you reviewing?

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* 2. What is your loved one's age?

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* 3. What is your loved one's gender?

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* 4. Is your loved one Hispanic or Latino?

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* 5. What is your loved one's race? (Select all that apply.)

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* 6. How long has your loved one received services from Preferred Behavioral Health Group?

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* 7. Your loved one's insurance type: Please select all that apply

Select the number that best represents your response.  Use N/A if a question does not apply to you. 

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* 8. Overall, I am satisfied with the services that my loved one receives here.

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* 9. I helped to choose my loved one’s services.

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* 10. I helped to choose my loved one’s treatment goals.

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* 11. The people helping my loved one stuck with us no matter what.

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* 12. I felt my loved one had someone to talk to when he/she was troubled. 

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* 13. I participated in my loved one’s treatment.

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* 14. The services my loved one and/or my family received were right for us.

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

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

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* 17. My family got the help we wanted for my loved one.

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* 18. My family got as much help as we needed for my loved one.

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* 19. Staff treated me with respect.

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* 20. Staff respected my family’s religious/spiritual beliefs.

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

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* 22. Staff were sensitive to my cultural/ethnic background.

As a direct result of services I received:

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* 23. My loved one is better at handling daily life.

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* 24. My loved one gets along better with family members.

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* 25. My loved one gets along better with friends and other people.

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* 26. My loved one is doing better in school and/or work.

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* 27. My loved one is better able to cope when things go wrong.

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

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* 29. My loved one is better able to do things he or she wants to do.

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* 30. My loved one’s encounters with the police have been reduced.

For questions 31 – 34 please answer for relationships with persons other than your mental health providers.

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

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* 32. I have people that I am comfortable talking with about my loved one’s problems.

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

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* 34. I have people with whom I can do enjoyable things.

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* 35. Comments

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