Contact - photoReferral Source Satisfaction Survey

We would appreciate your feedback regarding your experience with us. Please complete this survey and submit it to us. Information will be used to improve services, address concerns and determine future needs. Whenever possible, please indicate to which programs your comments are related.
Please Indicate which of the following referral source areas you represent:
Department of Social Services
Juvenile Court/ Probation Department
Education/School System
Managed Care/Insurance Company
Other Human Service Agency
Police Department
Other
Part I. Directions
Use the following scale to rate your overall experience with Y.O.U., Inc.

Strongly Agree - Agree - Disagree - Strongly Disagree
1. I received a timely response to my referral.
2. I found Y.O.U. Inc. staff responsive.
3. I received appropriate communication regarding my client(s) and their care.
4. I was included in the planning of services for my client(s) as appropriate.
5. The discharge/termination information I have received about my client(s) was:
a. Timely
b. Of good quality
c. Met my expectations
6. Overall, I am satisfied with my experience(s) with Y.O.U., Inc.
7. I would refer other clients to Y.O.U., Inc.
Part II. Directions
Use the following scale to rate your overall satisfaction of each component.

Excellent - Satisfactory - Poor
Community Based Services
Managed Care
Residential Services
Education and Employment Services
Outpatient Counseling Services
Part III. Comments
Please indicate strengths and/or ways that Y.O.U., Inc. can improve. If you answered "disagree" or "strongly disagree" to any of the above questions, please explain why.
If you would like to be contacted personally, please put your name and number below.
Name
 Telephone