Parent / Guardian: Clinical Satisfaction Survey
Date
*
-
Month
-
Day
Year
Date
Parent / Legal Guardian Name
*
First Name
Last Name
Youth's Name
*
First Name
Last Name
Therapist's Name
*
First Name
Last Name
Has your youth received therapy before at another organization / facility?
*
Yes
No
How long has your youth been seeing their current therapist at STTC?
*
Please Select
<1 month
1 month - 3 months
4 months - 6 months
7 months - 1 year
Over a year
Is your youth's therapist reliable and dependable for them?
1
2
3
4
5
1 star = Cancels on your youth, does not show up on time, does not communicate outside of therapy; 3 stars = Is reliable but could be better with engagement; 5 stars = Fully reliable and actively creates meaningful engagement
How well does your youth's therapist listen to and understand their concerns?
1
2
3
4
5
1 star = Very Poorly; 3 stars = Listens and acknowledges but does not integrate into care; 5 stars = Very integrated into care
Since beginning therapy, how would you rate the magnitude of the positive change you've seen in your youth's mental health?
1
2
3
4
5
1 star = Little-to-none; 3 stars = some change; 5 stars = transformative change
Do you feel your youth's therapist understands their values, identity and lived experiences?
1
2
3
4
5
1 star = little-to-no understanding; 3 stars = acknowledged but not impactful; 5 stars = fully integrated into therapy (treatment plan, coping mechanisms, etc.)
Do you understand your youth's diagnosis and treatment plan as identified and prepared by their therapist?
1
2
3
4
5
1 star = not at all and desire a lot more; 3 stars = some understanding but desire more detail; 5 stars = I understand in as much or as little detail as I desire.
Do you observe your youth actively practicing or discussing ways they are trying to incorporate recognition and coping mechanisms discussed with their therapist?
1
2
3
4
5
1 star = little-to-no observation; 3 stars = some instances but not consistent; 5 stars = actively discusses and tries to implement techniques discussed with therapist
To the extent you have sought feedback from your youth's therapist, have they been receptive to providing you progress reports, concerns or other meaningful takeaways?
1
2
3
4
5
1 star = not receptive or does not provide meaningful feedback; 3 stars = receptive but could be more specific about progress; 5 stars = actively engages and provides very in-depth feedback on progress, concerns, etc
Did your therapist provide additional resources, including group therapy offered by STTC, or other activities to support their one-on-one therapy?
Yes
No
Would you recommend your youth's therapist to a close friend seeking help for their youth?
Please Select
Yes - Absolutely
Yes - But with Reservations
No - I would refer them elsewhere
Additional Comments
Do you provide Spill The Tea Cafe consent to use any of your comments, on an anonymous basis, to promote youth access to mental health in Hawai'i?
*
Yes - STTC may use my commentary on an anonymous basis
No - I prefer my comments stay exclusively within the realm of Clinical Care
Submit
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