Consumer Services Satisfaction Survey

Childs Name:

Date completed:

Address: Street, Apt. #, City, State, Zip Code

Telephone #:

Family Ties Worker:

Guardian/ Parent’s Name:

Your Relationship to child:

Service Received:

Are you a:

1 – Was your worker available and responsive to you/child/ family?

2 – Was your worker helpful in assisting you/ your child(ren) in resolving some of the identified problems?

3 – Did your worker respect your family’s values and ways of doing things?

5 – Did you/ your child learn any new daily functioning skills from the worker?

6 – Will you/your child use these skills in the future?

7 – Did your worker help you/ your child(ren) address family problems?

If yes, explain:

8 – Was there anything else your worker could have done to meet you/ your child’s needs and help you/your child to accomplish the identified goals?

Explain:

9 – Is there any difference in you/ your child/family since being serviced by Family Ties?

10 – How helpful was Family Ties to you/ your child/family?

11 – Is your family continuing to receive Mental Health Services/ support since leaving Family Ties?

If yes or sometimes, please explain

12- Would you recommend Family Ties to a friend who needed mental health/support/family services?

Signature

(you may remain anonymous)