Client Customer Satisfaction & Information Survey
1.
I was helped in a timely manner.
Yes
No
None of the above
2.
I was treated with respect.
Yes
No
None of the above
3.
The staff were friendly and helpful.
Yes
No
None of the above
4.
I got the information and/or services I needed.
Yes
No
None of the above
5.
I was informed about other agency or community services.
Yes
No
None of the above
6.
I would recommend your agency to family and friends.
Yes
No
None of the above
7.
What is ONE thing you would change about the services you received from our agency?
8.
How did you learn about our agency? Select all that apply:
Family or Friend
Current or former agency client
United Way 211
Radio
Healthcare provider
Social media (Facebook, Instagram, etc.)
Local Church
Television
A state agency
Other social service agency
Brochure or Flyer
A Mailing
Websites/Internet
Newspaper
Phone Book
Billboard
The household I grew up in had received agency services.
Other (please specify)
9.
What services has your household received from our agency within the last 12 months? Select all that apply:
Energy Assistance (LIHEAP or PIPP)
Weatherization
Neighbor to Neighbor
Head Start/Early Head Start
Golden Meals
Rent or Water Assistance
Scholarship
HOME/HRAP
Benefit Access
10.
What kind of issues in your family or neighborhood are a concern to you?
11.
If given the opportunity, would you be willing to serve on a local board or committee that represents and makes decisions for families with low incomes?
Yes
No
If yes, please provide your name, phone number and email: