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* 1. If I had other choices of providers, I would still choose this agency for my services.

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* 2. I would recommend this agency to a friend or family member.

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* 3. I feel helped by the services I get here.

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* 4. Staff are responsive when I reach out to them.

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* 5. Services were available at times that are good for me.

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* 6. Staff here believe that I can grow, change, and recover.

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* 7.  Staff encourage me to take responsibility for how I live my life.

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* 8. As a direct result of the services I receive, the quality of my life has improved.

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* 9. Staff were sensitive to my cultural background (race, religion, language, age, communication, etc.)

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* 10. As a direct result of the services I receive, I do better in school, work , and/or community.

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* 11. As a direct result of the services I receive, what has gone well?

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* 12. As a direct result of the services I receive, what can be improved?

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* 13. Additional Comments?

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