Client Satisfaction Survey – Universal Support Agency

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Client Satisfaction Survey

Universal Support Agency > Client Satisfaction Survey

How did you like our services?

Send us your feedback. We welcome your opinions and suggestions.

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Consumer Satisfaction Survey

DATE

DATE SERVICES BEGAN

As we attempt to provide you with the best services possible, please share with us how you feel we are doing as your service provider.

NAME

PHONE NUMBER

GENDER

Male Female

RACE/ETHNICITY

AGE

Person receiving services/supports Family member Guardian

THE FOLLOWING SERVICES ARE BEING RECEIVED (CHECK ALL THAT APPLY):

Psychiatric Evaluation Diagnostic Assessment Medication/Somatic Individual Counseling Community Support Services Group Counseling

Please rate how you agree or disagree with the statements below by checking the response that best fits.

1- I AM HAPPY WITH THE SERVICES THAT I RECEIVE FROM UNIVERSAL SUPPORT AGENCY

Strongly Agree Mostly Agree Agree Disagree Strongly Disagree N/A

2- THE HOURS THAT SERVICES ARE AVAILABLE/PROVIDED ARE CONVENIENT.

Strongly Agree Mostly Agree Agree Disagree Strongly Disagree N/A

3- I CAN REACH SOMEONE AT UNIVERSAL SUPPORT AGENCY HEALTH SERVICES WHEN I NEED TO SPEAK TO SOMEONE

Strongly Agree Mostly Agree Agree Disagree Strongly Disagree N/A

4- STAFF ARE FLEXIBLE TO MY SCHEDULE.

Strongly Agree Mostly Agree Agree Disagree Strongly Disagree N/A

5- STAFF DEAL WITH/ADDRESS MY NEEDS IN A TIMELY MANNER.

Strongly Agree Mostly Agree Agree Disagree Strongly Disagree N/A

6- I AM ABLE TO SEE THE PSYCHIATRIST/HEALTH PROFESSIONAL WHEN I WANT TO.

Strongly Agree Mostly Agree Agree Disagree Strongly Disagree N/A

7- STAFF BELIEVE I CAN FULFILL MY DREAMS.

Strongly Agree Mostly Agree Agree Disagree Strongly Disagree N/A

8- THE STAFF ARE DEDICATED TO HELPING ME.

Strongly Agree Mostly Agree Agree Disagree Strongly Disagree N/A

9- I FEEL COMFORTABLE ASKING QUESTIONS.

Strongly Agree Mostly Agree Agree Disagree Strongly Disagree N/A

10- I FEEL FREE TO COMPLAIN ABOUT ANY ISSUE.

Strongly Agree Mostly Agree Agree Disagree Strongly Disagree N/A

11- I FEEL MY COMPLAINTS ARE HEARD AND TAKEN SERIOUSLY.

Strongly Agree Mostly Agree Agree Disagree Strongly Disagree N/A

12- STAFF RESPECT MY CHOICES EVEN IF THEY DO NOT AGREE WITH THEM.

Strongly Agree Mostly Agree Agree Disagree Strongly Disagree N/A

13- STAFF DO NOT DISCRIMINATE AGAINST ME.

Strongly Agree Mostly Agree Agree Disagree Strongly Disagree N/A

14- I FEEL THE GROUPS RUN AT NYA HEALTH SERVICES ARE USEFUL.

Strongly Agree Mostly Agree Agree Disagree Strongly Disagree N/A

15- SINCE RECEIVING SERVICES FROM NYA HEALTH SERVICES, I CAN DEAL WITH MY SITUATION BETTER.

Strongly Agree Mostly Agree Agree Disagree Strongly Disagree N/A

16- SINCE RECEIVING SERVICES FROM NYA HEALTH SERVICES, I GET ALONG BETTER WITH PEOPLE.

Strongly Agree Mostly Agree Agree Disagree Strongly Disagree N/A

PLEASE USE THE SPACE BELOW IF YOU WOULD LIKE TO WRITE MORE ABOUT ANY OF THE QUESTIONS THAT YOU ANSWERED ON THE PREVIOUS PAGE OR ADD ANY ADDITIONAL FEEDBACK THAT YOU WOULD LIKE TO GIVE.

ARE THERE ANY OTHER SERVICES THAT YOU WOULD LIKE NYA HEALTH SERVICES TO OFFER?

IF YOU COULD CHANGE ONE THING ABOUT NYA HEALTH SERVICES, WHAT WOULD IT BE?

ARE YOU INTERESTED IN BEING A MEMBER OF OR ACTIVELY PARTICIPATING ON NYA HEALTH SERVICES QUALITY IMPROVEMENT COMMITTEE?

Yes No

If your response is yes, you will be contacted by a member of the QI Department and/or receive information on NYA Health Services Quality Improvement Committee.

Thank you for taking the time to complete this survey. NYA Health Services truly values your input.

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