Six Month Services Satisfaction Survey
Client Name:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Date:
*
/
Month
/
Day
Year
Date
What services do you currently receive? Check all that apply
*
Individual Psychotherapy
Individual Rehabilitation
Family Psychotherapy
Group Rehabilitation
Group Psychotherapy
Case Management
On a Scale of 1-5, with 1 being Poor and 5 being Great, How closely did the above services align with your treatment plan goals?
*
1
2
3
4
5
How Helpful Were the Following Services (Select N/A if Not Applicable)
*
Not Helpful
Somewhat Helpful
Helpful
Very Helpful
Most Helpful
N/A
Individual Psychotherapy
Family Psychotherapy
Group Psychotherapy
Individual Rehabilitation
Group Rehabilitation
Case Management
What recommendations can you make about these services? (Consider content, times, frequency, relationship with clinician(s) etc.)
Would you like to add other types of services to your treatment plan?
*
Yes
No
If YES, which services would you like to add?
What was the major goal you hoped to accomplish during the past six month authorization period?
*
On a scale of 1-5, with 1 being poor and 5 being great, How well did your treatment align with that goal?
*
1
2
3
4
5
On a scale of 1-5, with 1 being little progress and 5 being a great deal of progress, How much progress do you feel you made on that goal?
*
1
2
3
4
5
Do you want to continue working on that goal?
*
Yes
No
Are there other problems or goals you would like to address during the upcoming authorization period?
*
Yes
No
If YES, what goals would you like to add to your treatment plan?
On a scale of 1-5, with 1 being not at all satisfied and 5 being very satisfied, How satisfied were you with how quickly you were able to start services?
*
1
2
3
4
5
If you made a crisis call were you able to reach your counselor right away? Leave blank if not applicable.
Yes
No
If NO, How long did it take for the counselor to call you back?
With 1 being Rarely and 5 being Almost Always, How often did your clinician(s) keep their scheduled appointments?
*
1
2
3
4
5
With 1 being Rarely and 5 being Almost Always, How often did your clinician(s) arrive on time for scheduled appointments?
*
1
2
3
4
5
Treatment Team Members
Please Type the Name of Each Treatment Team Member
Counselor:
*
Case Manager:
Other:
Additional Comments
Please let us know anything else you think would be helpful
Client/Guardian Signature
Clear
Date:
*
/
Month
/
Day
Year
Date
Submit
Should be Empty: