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English (US)
Oneonta Perception of Care Survey
What do you think about the services you receive?
Thank you for completing this voluntary survey. You can stop the survey at any time. Your services in this program will not be affected by whether or not you complete this survey. Your answers to this survey are confidential. They will not be linked to you or affect your participation in this program. Please do not write your name on this form. Your answers will be added with other client's answers to give program managers a picture of how the program is doing. Please note that the 3 open-ended questions at the end of the survey are for you to complete if there are other issues, things you see and/or concerns that you feel are not covered in the survey but want program managers to know about.
Type of particapant
*
Recovery
Which Center are you filling this out for?
Delhi
Oneonta
Please enter todays date
*
About how long have you been a part of this program?
One week
Two weeks
Three Weeks
Less than one month
1 month
2-3 months
4-5 months
6-8 months
9-11 months
1 year
1 1/2 years
2 years or more
How old are you?
17 or younger
18-25
21-24
25-34
35-44
45-54
55 or older
Gender
Male
Female
N/A
What is your race?
American Indian/Alaskan Native
Native Hawaiian or other Pacific Islander
Asian
White
Black or African American
Other
Are you Hispanic or Latino/a?
Yes
No
What kind of services are you receiving?
What is the primary reason you are receiving services?
Substance use
Mental Health
Both
Have you ever received services for this problem or a similar problem anywhere prior to coming here? (Check all that apply)
No
Yes. Inpatient rehab or residential treatment
Yes. Detox or crisis services
Yes. Outpatient or day treatment
Yes. Sober house or community residence
Yes. Other
Did you enter this program because a court judge, probation officer or parole officer required or told you to?
Yes
No
Did someone from this program (your counselor, a doctor, nurse, or other therapist) discuss with you the use of medication(s) to assist in recovery? Which kind of medications? (Check all that apply.)
Yes, to help me stop smoking or craving cigarettes and other tobacco products
Yes, to help me stop using or craving alcohol or drug
Yes, to help me treat my mental health or emotional proble
No. None of the above.
When you came for services, were you given information about your rights as a client
No
Yes
Have you been employed since you entered this program?
No. Not since entering the program.
Yes, but not currently emplaoyed
Yes. Currently emplaoyed
Have you been enrolled in school since you entered the program?
No. Not since entering the program
Yes, but not currently enrolled
Yes. Currently enrolled
What do you think about the services you receive?
Please check off only one for each row
Disagree
Somewhat agree
Agree
Strongly agree
When I needed services right away, I was able to see someone as soon as I wanted.
This program helped me develop a plan for when I feel stressed, anxious or unsaf
The people I receive services from spend enough time with me.
I helped to develop my service/treatment goals
The people I receive services from are sensitive to my cultural background (race, religion, language, sexual orientation, etc.).
I was given information about different services that were available to me
I was given enough information to effectively handle my problems.
Please check off only one for each row
Disagree
Somewhat agree
Agree
Strongly agree
As a result of the program services I have received, I am less bothered by my symptoms
As a result of the program services I have received, I am better able to cope when things go wrong.
As a result of the program services I have received, I am better able to accomplish the things I want to do.
As a result of the program services I have received, I am not likely to use alcohol and/or other drugs
As a result of the program services I have received, I am doing better at work/school. (If this does not apply to you, please leave it blank.)
As a result of the program services I have received, I get along with my teachers/boss. (If this does not apply to you, please leave it blank.)
Please check off only one for each row
Disagree
Somewhat agree
Agree
Strongly agree
There is someone who cares about whether I am doing better.
I have someone who will help when I have a problem
I have people in my life who are a positive influence.
The people I care about are supportive of my recovery.
People count on me to help them when they have a problem
I have friends who are clean and sober.
I have someone who will listen to me when I need to talk
Please check off only one for each row
Disagree
Somewhat agree
agree
Strongly agree
Using alcohol and/or drugs is a problem for me.
I need to work on my problems with alcohol and/or drugs
I would return to this program if I need help in the future
I would recommend this program to a friend or family member
What is this program doing right?
What could be done to improve the program?
Is there anything else about the program you would like to say?
Thank You! all submissions are anonymous.
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