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Client Survey
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Date
MM
/
DD
/
YYYY
Name (optional)
Your answer
Phone Number (optional
Your answer
Option 1
Clear selection
Name of Therapist/Prescriber (optional)
Your answer
Services
The services have been beneficial for me (or my family member)
Strongly Disagree
1
2
3
4
5
Strongly Agree
Clear selection
I am involved in treatment planning
Strongly Disagree
1
2
3
4
5
Strongly Agree
Clear selection
Services are available when I need them
Strongly Disagree
1
2
3
4
5
Strongly Agree
Clear selection
My confidentiality is respected
Strongly Disagree
1
2
3
4
5
Strongly Agree
Clear selection
I was given information about my rights
Strongly Disagree
1
2
3
4
5
Strongly Agree
Clear selection
I am heard and listened to by my therapist
Strongly Disagree
1
2
3
4
5
Strongly Agree
Clear selection
Psychiatry/Nurse practitioner appointments are helpful
Strongly Disagree
1
2
3
4
5
Strongly Agree
Clear selection
Medication management appointments are appropriate and useful
Strongly Disagree
1
2
3
4
5
Strongly Agree
Clear selection
I have improved relationships since treatment
Strongly Disagree
1
2
3
4
5
Strongly Agree
Clear selection
I am better able to deal with life
Strongly Disagree
1
2
3
4
5
Strongly Agree
Clear selection
I am better able to deal with life
Strongly Disagree
1
2
3
4
5
Strongly Agree
Clear selection
Phone calls are returned appropriately
Strongly Disagree
1
2
3
4
5
Strongly Agree
Clear selection
Please share feedback in your own words
Your answer
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