Clinic 5 Satisfaction Survey Form

CLINIC 5 SATISFACTION SURVEY

Please take a moment to fill out this survey
When did you begin with us? (just the year)
Discharge date if applicable.
1) Are you receiving or did you receive the help you need?

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5

1 is Worst, 5 is Best
Comments: Type here
2) Are you , or were you treated with respect and dignity?

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5

1 is Worst, 5 is Best
Comments:
Type a label
3) Did the staff take sufficient time to offer guidance/ support to you?

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5

1 is Worst, 5 is Best
Comments: Type here
4) Is the facility a comfortable, clean and easily accessible setting?

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5

1 is Worst, 5 is Best
Comments: Type here
5) Were you satisfied with the waiting time for services?

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1 is Worst, 5 is Best
Comments: Type here
6) Were you satisfied with counseling availability and staff services? (if applicable?)

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1 is Worst, 5 is Best
Comments: Type here
7) I would rate my overall level of satisfaction with my primary counselor as:

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5

1 is Worst, 5 is Best
Comments: Type here
8) I would rate my satisfaction with the physician/ nurse practitioner services

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5

1 is Worst, 5 is Best
Comments: Type here
9) Since entering services at Clinic 5 have you been arrested?

YesNo
Comments: Type here
10) How can Clinic 5 improve our services? List up to three things.
11) What new educational videos would you like to see on our YouTube channel?
12) If taking Buprenorphine how long have you been on it?

1-2 years3-4 years5-6 yearsMore than 6 years
13) Have you tapered since your initial dose of Buprenorphine? (Please indicate YES or NO) If yes what is your current dose?
14) Have you been diagnosed with any mental health disordersor struggling with additional addiction problems?
15) Have you been treated unfairly/poorly by a pharmacist/doctor/provider/dentist or other medical entity since being on Suboxone in the past 12 months?

YesNo
16) If yes to above question please explain.
17) Please leave any additional comments:
Thank you for taking the time to do this survey!
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CLINIC 5 SATISFACTION SURVEY

Thank you for taking the time to do this survey!