Patient Satisfaction Survey
Please answer the following 20 questions
Patient Name (optional- if you want this to be anonymous please leave blank)
First Name
Last Name
Todays Date
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Month
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Day
Year
Date
How long were you at the facility
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Who was your individual Therapist for 1 on 1 sessions
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What was the main reason you came to treatment? (Please the most honest answer here is the most helpful)
*
Drugs, Alcohol, Trauma, Mental Health, Homeless ETC ETC
What Program did you go through? Check as many as apply
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Residential - Willow Lake RTC
Transitional Program - Duplexes and IOP
IOP Clinical Services Only (when you live on your own and do IOP)
OP services (when you live on your own and do OP)
Did you Graduate or complete treatment as planned.
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Currently Attending
Yes
No
Other
1. I am satisfied with the services i've recieved at GMBHC
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1
2
3
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5
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9
10
Poor
Excellent
1 is Poor, 10 is Excellent
2. The pre-admissions process and getting to treatment was explained and effective?
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2
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10
Disagree
Agree
1 is Disagree, 10 is Agree
3. Group Therapy Services of the program are useful to my recovery.?
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1
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10
Disagree
Agree
1 is Disagree, 10 is Agree
4. Individual Therapy Services of the program are useful to my recovery?
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1
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9
10
Disagree
Agree
1 is Disagree, 10 is Agree
5. Case Management Services of the program are useful to my recovery.?
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Disagree
Agree
1 is Disagree, 10 is Agree
6. The staff have a good understanding of my problems?
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Disagree
Agree
1 is Disagree, 10 is Agree
7. I worked with staff to decide my treatment goals?
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10
Disagree
Agree
1 is Disagree, 10 is Agree
8. My rights and responsibilities had been clearly explained to me
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1
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10
Disagree
Agree
1 is Disagree, 10 is Agree
9. The program(s) are sensitive to people’s different needs and beliefs?
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1
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9
10
Disagree
Agree
1 is Disagree, 10 is Agree
10. The issue(s) that I need to address to get and stay sober and/or improve mental health symptoms were addressed in my treatment process?
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1
2
3
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10
Disagree
Agree
1 is Disagree, 10 is Agree
11. Overall I feel I got better as a result of my time in treatment at GMBHC?
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1
2
3
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9
10
Disagree
Agree
1 is Disagree, 10 is Agree
12. If you could add another aspect to the treatment program, what would it be?
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13. The residential technicians/BHT (direct support staff/Housing) were friendly and effective at improving your experience ?
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1
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Disagree
Agree
1 is Disagree, 10 is Agree
14. What can we do to improve our treatment process and structure for future patients?
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15. Was the Cleanliness of the facility up to your expectations during your stay
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1
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10
Disagree
Agree
1 is Disagree, 10 is Agree
16. Did you feel safe while traveling in a vehicle with a staff member driving?
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1
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Disagree
Agree
1 is Disagree, 10 is Agree
17. What was the most beneficial aspect of the program at GMBHC for you?
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18. If you had to point out one to two staff members at GMBHC that did a really good job who would it be?
(OPTIONAL QUESTION)
19. Compared to your experience with other behavioral health programs or general overall quality of care, how would you rate GMBHC on a scale of 1-10?
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1
2
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9
10
Low
Very High
1 is Low, 10 is Very High
20. How likely are you to recommend GMBHC to a friend or a family member?
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1
2
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5
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9
10
unlikely
Likely
1 is unlikely, 10 is Likely
Additional Comments
Submit
Should be Empty: