Client Satisfaction Survey

Question Title

* 1. Please enter todays date.

Date

Question Title

* 2. What is your race?

African American

Asian

Caucasian

Hispanic

Other

Question Title

* 3. What is your gender?

Male

Female

Question Title

* 4. Who referred you to the Human Services Department?

Question Title

* 5. Please indicate the program in which you participated.

Adolescent Intensive Outpatient

Anger Managment Group

Family Counseling

Individual Counseling

Question Title

* 6. Please indicate the counselor that you worked with.

Ashley Egleston

Bruce MacBeth

Jennifer Fria

Leo Beyda

Moshe Wax

Rosbel Puello

Sharon Moleski

Stephen Marks

Other (please specify)

Question Title

* 7. Please check the box that most closely represents your feeling about a particular aspect of the counseling program in which you were involved.

	Excellent	Very Good	Good	Fair	Poor
Convenience of service location	Convenience of service location Excellent	Convenience of service location Very Good	Convenience of service location Good	Convenience of service location Fair	Convenience of service location Poor
Convenience of appointment times	Convenience of appointment times Excellent	Convenience of appointment times Very Good	Convenience of appointment times Good	Convenience of appointment times Fair	Convenience of appointment times Poor
Comfort/atmosphere of facility	Comfort/atmosphere of facility Excellent	Comfort/atmosphere of facility Very Good	Comfort/atmosphere of facility Good	Comfort/atmosphere of facility Fair	Comfort/atmosphere of facility Poor
Competence and knowledge of the counselor	Competence and knowledge of the counselor Excellent	Competence and knowledge of the counselor Very Good	Competence and knowledge of the counselor Good	Competence and knowledge of the counselor Fair	Competence and knowledge of the counselor Poor
Quality of care and service	Quality of care and service Excellent	Quality of care and service Very Good	Quality of care and service Good	Quality of care and service Fair	Quality of care and service Poor
Thoughtfulness of initial evaluation	Thoughtfulness of initial evaluation Excellent	Thoughtfulness of initial evaluation Very Good	Thoughtfulness of initial evaluation Good	Thoughtfulness of initial evaluation Fair	Thoughtfulness of initial evaluation Poor
Amount of help you received	Amount of help you received Excellent	Amount of help you received Very Good	Amount of help you received Good	Amount of help you received Fair	Amount of help you received Poor
Degree of your improvement from the time of your initial visit	Degree of your improvement from the time of your initial visit Excellent	Degree of your improvement from the time of your initial visit Very Good	Degree of your improvement from the time of your initial visit Good	Degree of your improvement from the time of your initial visit Fair	Degree of your improvement from the time of your initial visit Poor
Degree to which you were helped to deal more effectivly with your problems	Degree to which you were helped to deal more effectivly with your problems Excellent	Degree to which you were helped to deal more effectivly with your problems Very Good	Degree to which you were helped to deal more effectivly with your problems Good	Degree to which you were helped to deal more effectivly with your problems Fair	Degree to which you were helped to deal more effectivly with your problems Poor
Improvement in how you feel compared to you initial visit	Improvement in how you feel compared to you initial visit Excellent	Improvement in how you feel compared to you initial visit Very Good	Improvement in how you feel compared to you initial visit Good	Improvement in how you feel compared to you initial visit Fair	Improvement in how you feel compared to you initial visit Poor
Overall satisfaction with your treatment	Overall satisfaction with your treatment Excellent	Overall satisfaction with your treatment Very Good	Overall satisfaction with your treatment Good	Overall satisfaction with your treatment Fair	Overall satisfaction with your treatment Poor
Value of treatment considering cost	Value of treatment considering cost Excellent	Value of treatment considering cost Very Good	Value of treatment considering cost Good	Value of treatment considering cost Fair	Value of treatment considering cost Poor
Response time from your first contact to your first appointment	Response time from your first contact to your first appointment Excellent	Response time from your first contact to your first appointment Very Good	Response time from your first contact to your first appointment Good	Response time from your first contact to your first appointment Fair	Response time from your first contact to your first appointment Poor
Adequacy of the explanation of procedures, fees, treatment, etc	Adequacy of the explanation of procedures, fees, treatment, etc Excellent	Adequacy of the explanation of procedures, fees, treatment, etc Very Good	Adequacy of the explanation of procedures, fees, treatment, etc Good	Adequacy of the explanation of procedures, fees, treatment, etc Fair	Adequacy of the explanation of procedures, fees, treatment, etc Poor
Friendliness/courtesy of your counselor	Friendliness/courtesy of your counselor Excellent	Friendliness/courtesy of your counselor Very Good	Friendliness/courtesy of your counselor Good	Friendliness/courtesy of your counselor Fair	Friendliness/courtesy of your counselor Poor
Attention to and respect to privacy that you received	Attention to and respect to privacy that you received Excellent	Attention to and respect to privacy that you received Very Good	Attention to and respect to privacy that you received Good	Attention to and respect to privacy that you received Fair	Attention to and respect to privacy that you received Poor
Personal interest in you and your problems	Personal interest in you and your problems Excellent	Personal interest in you and your problems Very Good	Personal interest in you and your problems Good	Personal interest in you and your problems Fair	Personal interest in you and your problems Poor
Attention given to what you had to say	Attention given to what you had to say Excellent	Attention given to what you had to say Very Good	Attention given to what you had to say Good	Attention given to what you had to say Fair	Attention given to what you had to say Poor
Comfort in referring a friend or relative	Comfort in referring a friend or relative Excellent	Comfort in referring a friend or relative Very Good	Comfort in referring a friend or relative Good	Comfort in referring a friend or relative Fair	Comfort in referring a friend or relative Poor
Comfort in returning if you needed help again	Comfort in returning if you needed help again Excellent	Comfort in returning if you needed help again Very Good	Comfort in returning if you needed help again Good	Comfort in returning if you needed help again Fair	Comfort in returning if you needed help again Poor

If you have chosen "Poor" for any catagory please let us know about any concerns you have.

Question Title

* 8. What is your overall satisfaction with the counseling program?

Excellent

Very Good

Good

Fair

Poor

Question Title

* 9. Would you recomend this program to a friend or family member?

Yes

Don't Know

Question Title

* 10. I began counseling in

Month

Year

Question Title

* 11. I ended counseling in

Month

Year

Question Title

* 12. My main reason for coming to counseling was

I thought it would help with a problem

It was required by court/probation

It was required by school

It was required by someone else

Question Title

* 13. The main issue we worked on in counseling was

Question Title

* 14. I ended counseling because

Question Title

* 15. What is your zip code?

ZIP/Postal Code: