Client Satisfaction Questionnaire Client Satisfaction Questionnaire 2020-7-27 Client Satisfaction Questionnaire Your Opinion Matters to Us! Please fill out the following survey and help us improve our service Program/Clinician* Date* MM slash DD slash YYYY Client name(optional) First Last What is your relationship with the child?* Parent Foster Parent Guardian Relative Self Current age of child*Gender of client* Female Male Race and Ethnic Background(optional) Hispanic/Latino Black/African American White/Caucasian Asian/Pacific Islander Native American Bi-racial Please indicate the number of sessions attended 1-5 sessions 6-10 sessions 11-20 sessions 20 or more Please select the statement that best describes your experienceQuestions1. I received a courteous and prompt response to my first request for services.* Strongly agree Agree Disagree Strongly disagree Does not apply 2. I found the building to be easily accessible, clean and comfortable.* Strongly agree Agree Disagree Strongly disagree Does not apply 3. I was given information about my rights and responsibilities, including grievance procedures and privacy laws.* Strongly agree Agree Disagree Strongly disagree Does not apply 4. Staff were polite and helpful (reception, telephone, billing)* Strongly agree Agree Disagree Strongly disagree Does not apply 5. We were involved in developing our goals for treatment.* Strongly agree Agree Disagree Strongly disagree Does not apply 6. Staff respected my culture/ethnic background* Strongly agree Agree Disagree Strongly disagree Does not apply 7. The therapist listened to our concerns.* Strongly agree Agree Disagree Strongly disagree Does not apply 8. When needed, I received a prompt response from my therapist/other available clinical staff.* Strongly agree Agree Disagree Strongly disagree Does not apply 9. I was satisfied with services received.* Strongly agree Agree Disagree Strongly disagree As a result of services:10. There has been improvement in the problems we sought help for.* Strongly agree Agree Disagree Strongly disagree Does not apply We are better able to continue working out problems on our own.* Strongly agree Agree Disagree Strongly disagree Does not apply 12. We were provided information about community services.* Strongly agree Agree Disagree Strongly disagree Does not apply 13. If we need help in the future, we are likely to return here* Strongly Agree Agree Disagree Strongly disagree Does not apply The program can improve the services by:Other Comments:If you would like to be contacted to further discuss this survey please supply a contact name and number:
