Consumer Satisfaction Survey

Your opinion counts! Please take a few moments to give us feedback so we can continue to provide our service. Thank
you for your input.

Name of Program: ____________________________ Date Survey Completed: __________________

Please check the answer that best describes how much you Agree or Disagree with the following:

Strongly I am Strongly Not

Disagree Agree
Disagree Neutral Agree Applicable
The program has helped me deal with my
problems.
I was able to make choices in the services I
received.
I received the services as described to me
during intake.
I was offered assistance in obtaining
employment or education.
I was satisfied with the services I received.
The facility was clean, comfortable, and inviting.
My questions were answered quickly.
I helped to develop my treatment plan.
I gained tools necessary for my recovery.
The program helped me with my overall needs.
The admission process was prompt and
courteous.
I felt understood and respected by staff.
The services I received has helped me to feel
better about myself.
I was able to participate in program activities
such as chores and groups.
I am leaving the program with a clear
discharge/follow up plan.
Program staff worked with me to develop a
written housing plan to follow upon discharge.
I was given assistance with obtaining benefits
(veterans, SSI/SSDI, Medicaid)
Staff were sensitive to my cultural background
(race, religion, language, etc.)

Addition comments to help us improve the program:

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