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Family/Caregiver Satisfaction and Feedback on Clinical and Program Culturally Responsive Services

Fresno County Department of Behavioral Health (DBH) strives to provide culturally competent services that reflect the cultural and linguistic diversity of our community.  Please indicate your level of agreement with the statements below by checking the box to the right of the statement that best fits your opinion.  If a question does not apply to you or your family member, check N/A.  The information you provide is anonymous and will be kept confidential.

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* Date:

Date

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* Name of Program (where your family member receives services):

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* Statement

  Strongly Disagree Disagree Neither Agree Nor Disagree Agree Strongly Agree N/A
1. The services my family member receives here help to achieve goals (getting a job, going to school, taking care of family, having friends, etc.)
2. Staff collaborate with me and my family member about treatment.
3. As a result of the services my family member receives here, they can handle daily life better.
4. The services my family member receives here helps them get along better with other people.
5. If my family member wants to receive services from a person from their own racial or ethnic group, staff help connect to those services.
6. There are interpreters easily available to assist me and/or my family member.
7. If my family member wants to receive services from a person of the same gender and/or from the LGBTQ+ community, staff help connect to those services.
8. Staff provide alternative services to meet my family member’s cultural treatment needs.
9. Staff respect my family member’s religious or spiritual beliefs.
10. Family and friends are included in my family member’s treatment, if requested.
11. Staff have an understanding of the diversity within my family member’s racial or ethnic group.
12. Some of the treatment staff are from my family member’s racial or ethnic group.
13. Staff treat me and my family member with respect.
14. The facility has pictures or reading material that show people from my family member’s racial or ethnic group.
15. The waiting room has brochures or handouts that my family member can easily understand about services that can be received here.

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* Please complete the following information about your family member who is receiving Behavioral Health services:

1. Age:

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* 2.  Ethnicity:  Are they Hispanic or Latino?

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* 2a).  If you they are Hispanic or Latino, what is their ethnicity? (Check all that apply)

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* 3.  Race: (Check all that apply)

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* 4.  Primary Language Spoken at Home:

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* 5.  Sexual Orientation:

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* 6. Gender Assigned at Birth:

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* 7. Current Gender Identity:

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* 8.  Military/Service Involvement:

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* 9.  Disabilities:  Does your family member have a disability?  A disability is a physical or mental impairment or medical condition lasting at least six months that substantially limits major life activity, which is not the result of severe mental illness.

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* 10. Did you require language assistance to complete this survey?

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