Client Satisfaction Survey

Client Satisfaction Survey
Today's Date *

Month Day Year
Date Hour Minutes AM/PM Option
What was the date of your most recent visit? *

Month Day Year
Date
What is your Zipcode? *
What services did you request/receive from First State? *

Food Pantry Emergency Services (rent/utility/medical bill) After School Services Case Management First Time Home Buyer's Counseling Foreclosure Counseling Mortgage Assistance through DEMAP Second Chance ReEntry Program Senior Community Service Employment Senior Companion Program Family Support Services (PSSF) Just seeking information
Overall, how satisfied or dissatisfied are you with First State? *

Very Satisfied Somewhat Satisfied Somewhat Dissatisfied Very Dissatisfied Neutral - Neither Satisfied or Dissatisfied
Which of the following words would you use to describe our services? (Check all that apply.) *

Reliable Unique High Quality Useful Good Value for the money Impractical Ineffective Poor Quality Unreliable
How well did our services meet your needs? *

Extremely Well Very Well Not So Well Somewhat Well Not Well At All
How would you rate the quality of our services? *

Very High Quality Low Quality High Quality Very Low Quality Neutral - Neither High nor Low Quality
How responsive have we been to your questions/concerns about our services? *

Extremely Responsive Very Responsive Somewhat Responsive Not So Responsive Not At All Responsive Not Applicable
How long have you been a client of our Agency? *

This Was My First Visit Less Than 6 months Six Months To A Year 1-2 Years 3 or More Years
How likely are you to request any of our services again? *

Extremely Likely Very Likely Somewhat Likely Not So Likely Not Likely At All
How important do the employees at First State CAA make you feel? *

Extremely Important Very Important Moderately Important Slightly Important Not At All Important
How politely did our representative treat you? *

Extremely Politely Very Politely Moderately Politely Slightly Politely Not At All Politely

How likely is it that you would recommend First State CAA to a friend? *

	1	2	3	4	5	6	7	8	9	10

1 is Not At All Likely, 10 is Extremely Likely

Do you have any comments, questions or concerns?
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