Name *

First Name

Last Name

Phone *

(###)

###

####

Date *

MM

DD

YYYY

Did staff listen to you and treat your concerns seriously?

At all times

Most of the time

Sometimes

Rarely

Never

Do you feel that the service has helped you to better understand and address your difficulties?

At all times

Most of the time

Sometimes

Rarely

Never

Did you feel involved in making choices about your treatment and care?

At all times

Most of the time

Sometimes

Rarely

Never

On reflection, did you get the help that mattered to you?

At all times

Most of the time

Sometimes

Rarely

Never

Did you have confidence in your therapist and his/her skills and techniques?

At all times

Most of the time

Sometimes

Rarely

Never