Date *

Agency/Organization *

1. How would you rate a quality of introduction to our services you had received before you started using our services (consider e.g., completeness and accuracy of informational session) *

1-Low 2 3 4-High

Please Explain what we can do to improve in this area *

2. How would you rate quality of our services (consider e.g., good relationship with clients, addressing appropriate problems with clients, linking them other resources) *

1-Low 2 3 4-High

Please explain what we can do to improve our performance in this area *

3. How would you rate the professional behavior of our staff (e.g., staff integrity, competency, returning phone calls within 24 hours, proper dress code, using the proper language)? *

1-Low 2 3 4-High

Please explain. What we can do to improve our performance in this criterion? *

4. How would you rate skills/knowledge/expertise of our clinical and administrative staff? *

1-Low 2 3 4-High

Please explain. What we can do to improve our performance in this criterion? *

5. How would you rate the quality and timeliness of our paperwork (please consider completeness, accuracy, relevancy, on-time submission, reporting period) *

1-Low 2 3 4-High

Please Explain. What we can do to improve or performance in this criterion? *

6. Are there any additional servics that you would like to see us providing? If yes, which ones? *

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