CLIENT FEEDBACK QUESTIONNAIRE  
Your participation is voluntary and anonymous.

1. I felt my problems were understood.
Never Always
0 1 2 3 4

Never Always
0 1 2 3 4

3. I had confidence in the help I received.
Never Always
0 1 2 3 4

Never Always
0 1 2 3 4

5. I was treated in a professional manner.
Never Always
0 1 2 3 4

Much Worse Much Improved
0 1 2 3 4

7. Do you feel you received the service you wanted?
Not at all Absolutely
0 1 2 3 4

Not at all Absolutely
0 1 2 3 4

9. Would you turn to family services for help again?
Not at all Absolutely
0 1 2 3 4

Not at all Absolutely
0 1 2 3 4

11. What did you find the most helpful?


13. What is the reason you stopped coming to Family Services?


15. Any additional comments you would care to make?

Service:
Program:
Staff:

Client:
Gender:
Age:
Racial or Ethnic Identity:

If you would like a response to the feedback you have provided, please provide your name and contact information:

Name:   Phone or E-mail:

  
Thank you for taking the time to help ensure our programs and services are of the highest quality.