Transition Consumer Survey
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We are constantly looking for ways to improve the quality of services. Please help us serve you and others better by completing the Consumer Satisfaction Survey. Answering the questions below should only take a few minutes. Your participation is completely voluntary and will help us ensure that services are better, more helpful, and complete. Please, hand over the survey to the team member who provided you with this form. (Optional)
Consumer’s name (Name of the child) ____________________________________
Date:________________
Person filling out this survey ________________________________ Relationship to client: _______________ We are interested in your honest opinion. Your answers are confidential and will not influence the services you or your child receives. Please indicate if you Strongly Agree, Agree, Disagree or Strongly Disagree with each of the following statements Strongly Agree
Agree
Disagree
Strongly Disagree
Not Applicable
1. Staff members were helpful. 2. Staff members were courteous and professional 3. Staff was interested in providing assistance 4. Response of the team members was timely 5. Staff knowledge of the field was adequate 6. The sessions were lively and energetic 7. The team members tried to understand how family's problems all fit together 8. My family knew exactly which problems we were working on 9. My family and the team members were honest and straightforward with each other 10. The team members’ recommendations made good use of family's strengths 11. The team members’ recommendations should help children to mature 12. The team members changed ways we interact with each other 13. Family and the team agreed upon the goals of the sessions 14. During the session, we talked about experiences that occurred in previous sessions
Overall, the experience with the services of Jireh Counseling and Consulting Service, Inc. was: Strongly negative Somewhat negative Neutral Somewhat positive Strongly positive Suggestions/Concerns/Comments: ____________________________________________________________________________________ ____________________________________________________________________________________ ________________ Thank You for Taking the Time to Complete this Survey! QI102.3--Transition Consumer Satisfaction Survey
Est. Mar 2008
Consumer’s name (Name of the child) ____________________________________
Date:________________
Person filling out this survey ________________________________ Relationship to client: _______________ We are interested in your honest opinion. Your answers are confidential and will not influence the services you or your child receives. Please indicate if you Strongly Agree, Agree, Disagree or Strongly Disagree with each of the following statements Strongly Agree
Agree
Disagree
Strongly Disagree
Not Applicable
1. Staff members were helpful. 2. Staff members were courteous and professional 3. Staff was interested in providing assistance 4. Response of the team members was timely 5. Staff knowledge of the field was adequate 6. The sessions were lively and energetic 7. The team members tried to understand how family's problems all fit together 8. My family knew exactly which problems we were working on 9. My family and the team members were honest and straightforward with each other 10. The team members’ recommendations made good use of family's strengths 11. The team members’ recommendations should help children to mature 12. The team members changed ways we interact with each other 13. Family and the team agreed upon the goals of the sessions 14. During the session, we talked about experiences that occurred in previous sessions
Overall, the experience with the services of Jireh Counseling and Consulting Service, Inc. was: Strongly negative Somewhat negative Neutral Somewhat positive Strongly positive Suggestions/Concerns/Comments: ____________________________________________________________________________________ ____________________________________________________________________________________ ________________ Thank You for Taking the Time to Complete this Survey! QI102.3--Transition Consumer Satisfaction Survey
Est. Mar 2008
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