Are you a child or adult completing the survey?
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Adult (Over 18)
Child (Under 18)
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).
Based on my (my family's) experiences with this program
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Rows
Strongly Agree
Agree
Disagree
Strongly Disagree
Not applicable
1. I would recommend this service to someone I know
2. Overall, I am satisfied with this service and the. services I. received here.
3. The staff respected my cultural background (race, ethnicity, religion, language, age, sexual orientation, etc.)
4. The staff communicated and provided information in a way that I could understand
5. During my most recent interaction with Omid, the. staff treated me with courtesy and respect.
6. The staff helped me receive services from other programs or agencies.
7. This service has helped me improve my relationships with family, friends, and/or co-workers.
8. This service has helped me develop or improve skills for coping with daily stresses, depression and/or anxiety.
9. As a direct result of the services I received here. I am better able to take care of myself or do things for myself.
10. I will use what I learned from this service in the future.
11. Additional Feedback
12. What is your age?
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18-25 years
26-39 years
40-59 years
60 years or older
13. What is your gender?
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Male
Female
Non-Binary
14. 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
Based on my experiences with this program:
Rows
Yes
No
N/A
Are you happy with the help you get here?
Do you feel like you get good help when you come here?
Are the people who work here nice to you?
Do the people here talk to you and listen to you?
Do you feel like the people here understand you?
Do you feel comfortable when you are here?
Do you think the help you get here makes things better for you?
Do you like the activities and tools we use to help you?
Do you get enough time to talk about your feelings and problems?
Would you tell your friends to come here if they need help?
How old are you?
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Are you a boy or girl or non-binary or other: Please Fill?
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Did someone help you complete this survey?
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No
Yes
Thank you for your feedback!
Your feedback is important to us!
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