Client Satisfaction Survey

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

"*" indicates required fields

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)*

Discharge Date (mm/dd/yyyy)*

Are you interested in Rockland's Alumni Program?*

Yes

INTAKE - When you first called Rockland Treatment Center:

Were your questions handled in a timely manner?*

Were you treated with courtesy?*

Was the program explained to you?*

Were your financial responsibilities explained to you?*

Any comments on how to improve the intake experience?*

THE PROGRAM:

How would you rate your overall experience so far?*

Have you been working on important issues in treatment?*

Are you being educated about substance abuse?*

Are you being educated about your medications?*

Do you feel you are receiving all services you needed?*

Do you feel safe at Rockland Treatment Center?*

Would you recommend Rockland Treatment Center?*

Yes

Would you come back if you had to?*

Yes

Any comments on how to improve the program?*

THE COUNSELORS:

How would you rate the performance of your counselor so far?*

Do you feel there are enough counselors?*

Yes

Were you made aware of and did you have input into the creation of your treatment plan?*

Yes

Is your counselor giving you as much time as you need?*

Yes

Most liked groups so far? Please explain.*

Least liked groups so far? Please explain.*

HOUSING & TRANSPORTATION:

How would you rate the accommodations?*

Did techs get you to groups and appointments on time?*

Yes

How would you rate our driving?*

How would you rate the recreation activities?*

Any comments on how to improve housing or transportation? Please explain.*

OTHER:

How would you rate the performance of the Tech staff?*

How would you rate the performance of support staff?*

Are people using drugs or alcohol at Rockland Treatment Center?*

Yes

Is there anything else you would like to tell us?*