LCSC Satisfaction Survey

1

Hi, please select an option below* This field is required.

Satisfaction Survey

Suggestion

Complaint

Change Information

2

Suggestion* This field is required.please let us know if you have any suggestions for LCSC

3

Complaint* This field is required.please register your complaint below

4

Change of Information* This field is required.please input your Name and Telephone number and then list any changed information

5

I am a:* This field is required.please select one

Person receiving services

Parent or family member

6

Approximately when did you/your child start coming for services? * This field is required.

Date

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When I/my child started services at LCSC, I would rate my symptoms as:* This field is required.

1
2
3
4
5
6
7
8
9
10

MILD

SEVERE

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It is easy to make convenient appointments in person or remotely if needed:* This field is required.

All of the time

Most of the time

Some of the time

Rarely

Never

10

The LCSC staff treat me/my child with respect:* This field is required.

All of the time

Most of the time

Some of the time

Rarely

Never

11

The environment at LCSC is welcoming:* This field is required.

All of the time

Most of the time

Some of the time

Rarely

Never

12

LCSC staff encourage me/my child to participate in my recovery plan and treatment:* This field is required.

All of the time

Most of the time

Some of the time

Rarely

Never

13

LCSC staff give me/my child referrals and follows up with referrals when needed:* This field is required.

All of the time

Most of the time

Some of the time

Rarely

Never

14

LCSC staff helps me/my child have hope for the future:* This field is required.

All of the time

Most of the time

Some of the time

Rarely

Never

15

Do you/your child receive more than one service from LCSC * This field is required.e.g. dietician, mentor, neuropsych evaluation,, meals, etc.

YESNO

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Comment:Optional. To skip, press next.

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NameTo skip, press submit.

First Name

Last Name