Individual Satisfaction Survey Still Waters Professional Counseling Services, Inc. Survey ExplanationIn order to better to serve you (or the individual you represent) better, we would love your input. We will use this survey data to improve our services and customer service.Survey InstructionsPlease honestly answer all of the questions and provide as much detail in the comments sections as you are comfortable with. ALL SURVEYS WILL BE HELD IN THE STRICTEST OF CONFIDENCE. You have the option to remain anonymous or to be contacted concerning your responses. Note: This survey takes less than 5 minutes to complete.Date of Survey Date Format: MM slash DD slash YYYY (1) Demographics1_1. Please check which best describes you. Individual over 18 years of age. Individual under 18 years of age. Legal Representative of the Individual Person taking this survey. Select only one answer.1_2. Date of Birth - of Individual Receiving Services MM DD YYYY 1_3. Gender - of Individual Receiving Services Male Female Transgender 1_4. Ethnicity - of Individual Receiving Services1_5. County - of Individual Receiving Services(2) Contact Information (Optional)If you wish to be contacted by management concerning issues discussed in this survey, please provide name(s) and contact information below. Providing name(s) is OPTIONAL.2_1. Desire to be contacted concerning this survey I wish to be contacted by management. I will contact management. I wish to remain anonymous. 2_2. Name - Individual receiving or has received services (Optional) First Middle Last 2_3. Name - Legal Representative of the Individual listed above (Optional) First Last 2_4. Contact - Phone (Optional)(3) General Questions3_1. What is your (or the person you legally represent) current status concerning receiving services? Currently Receiving Services - First Time Currently Receiving Services - Returning Discharged from Services - Completed Discharge from Services - Wish to Return 3_2. How long have you (or the individual you represent) received services from SWPCI? Less than 1 month Less than 1 year 1 year or more 3_3_a. What services are/were you (or the individual you legally represent) receiving from SWPCI? (IFI) Intensive Family Intervention/Intensive Core Individual or Family Counseling Medication Management DFCS Assessment Other Services (Please specify in 3_3_b.) Select all that apply.3_3_b. Other Services Description3_4_a. How did you hear about SWPCI? (DFCS) The Dept. of Family and Children Services (DJJ) The Dept. of Juvenile Justice Primary Care Physician Psychiatrist Friend/Relative School Internet - Search Internet - Social Media Unsure Inpatient Facility (Please specify in (3_4_b.) Other Source (Please specify in 3_4_c.) 3_4_b. Inpatient FacilitySkip if not applicable.3_4_c. Other SourceSkip if not applicable.3_5. Would you (or the individual you represent) have preferred to be MORE actively involved with treatment decisions? Yes No Unsure 3_6_a. If you (or the individual you represent) has experienced any out of home placements in the last 3 months, please select placement location(s). Not applicable With another family member Hospital (YDC) Youth Detention Center Jail Rehabilitation Center Other Location (Please Specify in 3_6_b.) 3_6_b. Other Location of Out of Home Placement Description3_7. Have you ever called the SWPCI crisis phone number? Yes No I did not know there is a SWPCI Crisis Phone Number (4) SWPCI Office StaffOffice staff refers to administrative staff like front desk, directors and managers. Exclude comments concerning your counselor(s) in this section.4_1. Rate level of satisfaction with SWPCI OFFICE STAFF in regards to customer service? Extremely Dissatisfied Moderately Dissatified Neutral Moderately Satisfied Extremely Satisfied Please rate based on issues such as making appointments, friendliness, professionalism etc.4_2. Comments - Concerning SWPCI OFFICE STAFFNegative and positive comments welcomed.(5) Counselor(s)(5_1) Counselor(s) - Appointments and Sessions5_1_a. On a weekly basis, how many times did you (or the individual you represent) see your counselor(s)? 1-2 Times Weekly 3 or More Times Weekly 1 Time a Month Less than 1 Time a Month 5_1_b. Approximately how long are your (or the individual you represent's) counseling sessions? 15 Minutes 30 Minutes 45 Minutes 1 hour Over one hour 5_1_c. Does your counselor(s) schedule appointments ahead of time? No, they just show up unscheduled Yes, they always schedule ahead of time Sometimes they schedule appointments, sometimes they just show up 5_1_d. When scheduled, does your counselor(s) show up for appointments on time (within 20 minutes of appointment time)? Always on time for appointments Always late for appointments Occasionally late for appointments Not applicable, because never schedules appointments 5_1_e. To accommodate the counselors schedule, how many times in the last 3 months has your counselor cancelled or rescheduled appointments? Not at all 1 to 3 Times 4 or More Times Sometimes does not show up for appointments at all 5_1_f. Comments - Concerning APPOINTMENTS AND SESSIONSNegative and Positive comments welcomed.(5_2) Counselor(s) - Performance and Outcomes5_2_a. Rate level of satisfaction with SWPCI COUNSELOR(s) in regards to customer service. Extremely Dissatisfied Moderately Dissatified Neutral Moderately Satisfied Extremely Satisfied Please rate based on issues such as making friendliness, abilities and professionalism etc. 5_2_b. Do you feel that you (or the individual you represent) has benefited from receiving counseling from SWPCI? Yes No Unsure 5_2_c. Rate the overall effectiveness of the counseling services you (or the individual you represent's) received from SWPCI? Poor Fair Good Great Excellent 5_2_d. Comments - Concerning PERFORMANCE AND OUTCOMESNegative and Positive comments welcomed.(6) Telehealth Services6_1. Have you (or the individual you represent) received services using our Telehealth Service? Yes No I was not aware that SWPCI had Telehealth Services 6_2. How would you rate the overall effectiveness of Telehealth Services? Poor Fair Good Great Excellent Not applicable 6_3. Comments - Concerning TELEHEALTH SERVICESPositive and negative comments welcome.(7) Still Waters Overall Performane7_1. How likely are you to recommend SWPCI to someone else? Not Likely Somewhat Likely Neutral Likely Very Likely Example: Would you recommend SWPCI to a friend, relative, co-worker etc.?7_2. How would you rate your (or the individual you represent's) level of satisfaction with SWPCI, as a company? Extremely Dissatisfied Moderately Dissatified Neutral Moderately Satisfied Extremely Satisfied 7_3. Is there anything that would (or would have) made your experience with SWPCI better? No, I am satisfied with the service(s) I receive(d) at SWPCI. Yes, and my comments and suggestions are listed below. Yes, but I prefer not to comment. 7_4. Comments - On STILL WATERS OVERALL PERFORMANCEComments and suggestions welcomed.(8) For Internal Use OnlyUsed for SWPCI staff, contractors and interns only.8_1_a. Surveyor if other than individual. First Last 8_1_b. Email - Surveyor Visits: 22
