Alpha & Omega Therapy and Doula Services, 6 Month Satisfaction Survey
To be filled out by client or parent/guardian
Client name
Address
Street Address
Street Address, Line 2
City
State
Postal/Zip Code
Phone
Email
Date
-
Month
-
Day
Year
Date
What services do you currently receive? Check all that apply
Individual Psychotherapy
Family Psychotherapy
Individual Rehabilitation
Group Rehabilitation
Group Psychotherapy
Case Management
Individual Psychotherapy: On a scale of 1-5 with 5 being the best how, well did your services line up with your treatment goals?
1
2
3
4
5
N/A
Family Psychotherapy: On a scale of 1-5, with 5 being the best, how well did your services line up with your treatment goals?
1
2
3
4
5
N/A
Individual Rehabilitation: On a scale of 1-5, with 5 being the best, how well did your services line up with your treatment goals?
1
2
3
4
5
N/A
Group Rehabilitation: On a scale of 1-5, with 5 being the best, how well did your services line up with your treatment goals?
1
2
3
4
5
N/A
Group Psychotherapy: On a scale of 1-5, with 5 being the best, how well did your services line up with your treatment goals?
1
2
3
4
5
N/A
Case Management: On a scale of 1-5, with 5 being the best, how well did your services line up with your treatment goals?
1
2
3
4
5
N/A
Would you like to add other types of services to your Treatment Plan?
Yes
No
What recommendations can you make about the services you received? (Consider content, times, frequency, relationships with clinician(s), etc.)
What was the major goal you wanted to accomplish during the last 6 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 to work on that goal?
Yes
No
If you are not satisfied with the progress on that goal, what do you think hindered that process?
On a scale of 1-5, with 1 not being satisfied all and 5 being very satisfied, how satisfied were you on 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?
Yes
No
N/A
With 1 being rarely and 5 being almost always, how often did you clinician(s) keep their scheduled appointments?
1
2
3
4
5
With 1 being rarely and 5 being almost always, how often were your clinician(s) on time for your appointments?
1
2
3
4
5
Please add any additional comments on how we can improve our services.
Treatment Team Members
Please type the name of each Treatment Team Member
Mental Health Therapist:
Case Manager:
Other:
Client or Parent/Guardian Signature
Date
-
Month
-
Day
Year
Date
Email address for the clinician who is updating your Treatment Plan with you.
If unknown, you may send to AlphaandOmegatherapydoula@yahoo.com
Should be Empty: