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Please answer all survey questions in accordance with the directions and choices provided. Also note that many questions include a "Comments" box that you may use to offer additional thoughts or suggestions.  At the bottom of the last page in the survey is a box labeled "Done." When you have finished, click this box to return your completed survey.


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* 1. How often did you (or your child) see someone or get an appointment with someone as soon as you wanted?

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* 2. How often were you (or your child) seen within 15 minutes of your (or your child’s) appointment?

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* 3. How often did the office staff you (or your child) talked with, treat you (or your child) with courtesy and respect?

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* 4. How often were the office staff you (or your child) talked with, as helpful as you (or your child) thought they should be?

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* 5. How often did the people you (or your child) went to for counseling or treatment listen carefully to you (or your child) and show respect for what you (or your child) had to say?

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* 6. How often did the people you (or your child) went to for counseling or treatment explain things in a way you (or your child) could understand?

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* 7. How often did the people you (or your child) went to for counseling or treatment spend enough time with you (or your child)?

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* 8. Did you (or your child) take any prescription medicines as part of your treatment?

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* 9. Were you (or your child) told what side effects of those medicines to watch for?

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* 10. How often were you/your family/your friends involved as much as you (or your child) wanted in your (or your child’s) counseling or treatment?

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* 11. Were you (or your child) told about self-help or support groups, such as consumer-run groups or 12‑step programs, or other community resources for housing, transportation, childcare, etc?

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* 12. Does your (or your child’s) language, race, religion, ethnic background or culture make any difference in the kind of counseling or treatment you (or your child) need?

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* 13. Was the care you (or your child) received responsive to those needs?

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* 14. How often did you (or your child) feel comfortable raising any issues or concerns you (or your child) had about your (or your child’s) counseling or treatment?

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* 15. Using any number from 0 to 10, where 0 is the worst counseling or treatment possible and 10 is the best counseling or treatment possible, what number would you use to rate all your (or your child’s) counseling or treatment?

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* 16. How would you rate your (or your child’s) ability to deal with daily problems now?

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* 17. In general, how would you rate your (or your child’s) overall health now?

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* 18. What was your (or your child’s) most recent counseling or treatment for?  Check all that apply.

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* 19. In the last 12 months, how many times did you (or your child) go to an emergency room or crisis center to get counseling or treatment for yourself (or your child)?

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* 20. What is your (or your child’s) age now?

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* 21. Are you (or your child) male or female or undifferentiated?

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* 22. What is the highest grade or level of school that you (or your child) have completed?

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* 23. Are you (or your child) of Hispanic or Latino origin or descent?

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* 24. What is your (or your child’s) race? Please mark one or more.

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* 25. Where did you (or your child) receive services?

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