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Adult Client Questionnaire and Empowerment and Satisfaction Survey

As a client of our agency, you received services in response to a traumatic event or events. In order to provide you with the best possible services, we would like to know how much our agency helped you to deal with that trauma. Please read the following statements about the services and other aspects of the agency and select if you strongly agree, somewhat agree, are neutral, somewhat disagree, or strongly disagree with the statements. If the question is not relevant to you, select "N/A" for Not Applicable.

Client Services Outcomes

Date:
Staff helped me feel hopeful and believe that things could change for the better:
Strongly Disagree
Disagree
No change
Agree
Strongly Agree
N/A
The services helped me learn skills and actions to help myself. The services helped me identify supports in my life or community:
Strongly Disagree
Disagree
No change
Agree
Strongly Agree
N/A
The services helped me learn more about the options and choices available to me:
Strongly Disagree
Disagree
No change
Agree
Strongly Agree
N/A
Staff respected my needs, identity, and background:
Strongly Disagree
Disagree
No change
Agree
Strongly Agree
N/A
The times and places of the services worked for me:
Strongly Disagree
Disagree
No change
Agree
Strongly Agree
N/A
I helped decide the kinds of services I would receive:
Strongly Disagree
Disagree
No change
Agree
Strongly Agree
N/A
I would use these services again or recommend them to a friend:
Strongly Disagree
Disagree
No change
Agree
Strongly Agree
N/A
What was the most helpful part of the services?
How could the services be better?
Is there anything else you'd like us to know?
Age:
Demographics:
(Select all that apply)













What kinds of services have you used with this provider?
(Select all that apply)






Other Defined: