Satisfaction/Feedback Survey
Please check which services your received (select all that apply)
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Therapy
Psychological Assessment/Testing
Workshop/Training
Group Therapy
Community Support (CalAIM, Housing)
Home Visitation Program (0-5)
Senior Support
Other
Optional: If you'd like, please provide more details about the services you received (such as the class/workshop name or feedback for a clinician or staff member).
Approximately, how long have you received services here?
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Less than 1 month ago
1-3 months
4-6 months
7-9 months
10-12 months
More than 12 months
What is your gender?
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Male
Female
Other
What is your age?
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0-5 years
6-13 years
14-18 years
18-25 years
26-39 years
40-59 years
60-64 years
65 years or older
Based on your (or your family’s) experience with this program, please indicate how much you agree with the following statements.
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Rows
Strongly Agree
Agree
Disagree
Strongly Disagree
Not applicable
1. I would recommend this program to others.
2. Overall, I am satisfied with the services or activities I participated in.
3. Staff treated me with courtesy and respect.
4. Staff respected my background, identity, and personal experiences (such as culture, language, age, or beliefs).
5. Staff explained information in a way that I could understand.
6. Staff helped me understand what to expect from the services or activities.hat to expect from the services or activities provided.
7. Staff were helpful when I needed support, information, or resources.
8. When appropriate, staff helped connect me to other helpful services or programs.
9. Participating in this program helped meet my needs or improve my well-being.
10. I plan to use something I learned from this program in the future.
Think about your time in this program. Tell us how much you agree with each sentence.
Rows
Yes, a lot
Yes, a little
Not really
No
Not sure/ Not applicable
1. I would tell a friend or family member to come to this program.
2. I liked the program or activities I joined.
3. The staff were kind and respectful to me.
4. The staff respected who I am and where I come from.
5. The staff explained things in a way I could understand.
6. I understood what was going to happen in the program or activity.
7. The staff were helpful when I needed help or had questions.
8. The staff helped me find other help when I needed it.
9. I learned something helpful or felt better because of this program.
10. I will use something I learned here in the future.
Did someone help you complete this survey?
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No
Yes
Additional Feedback/What was the most helpful?
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Optional: If you would like us to contact you regarding your feedback, please leave a name and contact phone number/email address.
Thank you for your feedback!
Your feedback is important to us!
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