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LCSC Satisfaction Survey
Hi there, please take a moment to complete this brief survey.
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HIPAA
Compliance
1
I am a:
*
This field is required.
please select one
Person receiving services
Parent or family member
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2
Approximately when did you/your child begin services?
-
Date
Month
Day
Year
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3
When I/my child started services at LCSC, I would rate my symptoms as:
1
2
3
4
5
6
7
8
9
10
MILD
SEVERE
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4
Today, I would rate my/my child's symptoms as:
1
2
3
4
5
6
7
8
9
10
MILD
SEVERE
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5
It is easy to make convenient appointments in person or remotely if needed:
All of the time
Most of the time
Some of the time
Rarely
Never
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6
The LCSC staff treat me/my child with respect:
All of the time
Most of the time
Some of the time
Rarely
Never
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7
The environment at LCSC is welcoming:
All of the time
Most of the time
Some of the time
Rarely
Never
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8
LCSC staff encourage me/my child to participate in my recovery plan and treatment:
All of the time
Most of the time
Some of the time
Rarely
Never
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9
LCSC staff give me/my child referrals and follows up with referrals when needed:
All of the time
Most of the time
Some of the time
Rarely
Never
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10
LCSC staff helps me/my child have hope for the future:
All of the time
Most of the time
Some of the time
Rarely
Never
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11
Do you/your child receive more than one service from LCSC
e.g. dietician, mentor, neuropsych evaluation,, meals, etc.
YES
NO
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12
How satisfied are you with the multiple services that you/your child receive from LCSC?
1
2
3
4
5
6
7
8
9
10
LESS SATISFIED
VERY SATISFIED
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13
Comment:
Optional. To skip, press next.
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14
Name (OPTIONAL)
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First Name
Last Name
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