Client Satisfaction Survey

Please try your best to fill out the form below. If you have any questions, please ask your client intake coordinator.

Client First Name*
Client Last Name*
Client Mobile Phone
Client Email Address
Client Future Address*
Street Address Address Line 2 City State ZIP Code
Admission Date (mm/dd/yyyy)*
Month
Day
Year
Discharge Date (mm/dd/yyyy)*
Month
Day
Year
Are you interested in Rockland's Alumni Program?*
- Yes
- No
INTAKE - When you first called Rockland Treatment Center:
Were your questions handled in a timely manner?*
Excellent Very Good Good Needs Improvement Poor
Were you treated with courtesy?*
Excellent Very Good Good Needs Improvement Poor
Was the program explained to you?*
Excellent Very Good Good Needs Improvement Poor
Were your financial responsibilities explained to you?*
Excellent Very Good Good Needs Improvement Poor
Any comments on how to improve the intake experience?*
THE PROGRAM:
How would you rate your overall experience so far?*
Excellent Very Good Good Needs Improvement Poor
Have you been working on important issues in treatment?*
Excellent Very Good Good Needs Improvement Poor
Are you being educated about substance abuse?*
Excellent Very Good Good Needs Improvement Poor
Are you being educated about your medications?*
Excellent Very Good Good Needs Improvement Poor
Do you feel you are receiving all services you needed?*
Excellent Very Good Good Needs Improvement Poor
Do you feel safe at Rockland Treatment Center?*
Excellent Very Good Good Needs Improvement Poor
Would you recommend Rockland Treatment Center?*
- Yes
- No
Would you come back if you had to?*
- Yes
- No
Any comments on how to improve the program?*
THE COUNSELORS:
How would you rate the performance of your counselor so far?*
Excellent Very Good Good Needs Improvement Poor
Do you feel there are enough counselors?*
- Yes
- No
Were you made aware of and did you have input into the creation of your treatment plan?*
- Yes
- No
Is your counselor giving you as much time as you need?*
- Yes
- No
Most liked groups so far? Please explain.*
Least liked groups so far? Please explain.*
HOUSING & TRANSPORTATION:
How would you rate the accommodations?*
Excellent Very Good Good Needs Improvement Poor
Did techs get you to groups and appointments on time?*
- Yes
- No
How would you rate our driving?*
Excellent Very Good Good Needs Improvement Poor
How would you rate the recreation activities?*
Excellent Very Good Good Needs Improvement Poor
Any comments on how to improve housing or transportation? Please explain.*
OTHER:
How would you rate the performance of the Tech staff?*
Excellent Very Good Good Needs Improvement Poor
How would you rate the performance of support staff?*
Excellent Very Good Good Needs Improvement Poor
Are people using drugs or alcohol at Rockland Treatment Center?*
- Yes
- No
Is there anything else you would like to tell us?*
Phone
This field is for validation purposes and should be left unchanged.

Client Satisfaction Survey

INTAKE - When you first called Rockland Treatment Center:

THE PROGRAM:

THE COUNSELORS:

HOUSING & TRANSPORTATION:

OTHER:

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