Adult Services Satisfaction Survey

In order to provide the best possible services, we need to know what you think about the services you received during the last THREE MONTHS, the people who provided it, and the results. There is space at the end of the survey to comment on any of your answers. Please answer all questions as they pertain to or are a result of services received at your agency.

Age of person receiving services *


Highest Grade Level Achieved:

Residence of Person Receiving Services

Length of Time receiving services:*

Transportation Used to Get to Service Provider

Agency at which you receive services:*

I like the services that I received here. *

If I had other choices, I would still get services from this agency. *

I would recommend this agency to a friend or family member*

The location of services was convenient (parking, public transportation, distance, etc.). *

Staff were willing to see me as often as I felt it was necessary. *

Services were available at times that were good for me. *

I was able to get all the services I thought I needed. *

I was able to see a psychiatrist when I wanted to. *

Staff here believe that I can grow, change and recover. *

I felt comfortable asking questions about my treatment and/or medication. *

I felt free to complain. *

I was given information about my rights. *

Staff encouraged me to take responsibility for how I live my life. *

Staff told me what side effects to watch out for. *

Staff respected my wishes about who is and who is not to be given information about my treatment. *

I, not staff, decided my treatment goals. *

Staff were sensitive to my cultural background (race, religion, language, etc.) *

Staff helped me obtain the information I needed so that I could take charge of managing my illness*

I was encouraged to use consumer-run programs (support groups, drop-in centers, crisis phone line, 12-Step Programs, etc.). *

I deal more effectively with daily problems. *

I am better able to control my life*

I am better able to deal with crisis*

I am getting along better with my family. *

I do better in social situations. *

I do better in school and/or work. *

My housing situation has improved. *

My symptoms are not bothering me as much. *

I do things that are more meaningful to me. *

I do things that are more meaningful to me. *

I am better able to handle things when they go wrong. *

I am better able to do things that I want to do.

I am happy with the friendships I have. *

I have people with whom I can do enjoyable things. *

I feel I belong in my community. *

In a crisis, I would have the support I need from family or friends. *

Please use this space to comment on any of your answers. Also, if there were areas which were not covered by this questionnaire that you feel should have been, please write them here.
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