Last Updated: April 12, 2002		Bay State Community Services is committed to providing the best care to you and your family. In order for us to be sure that we are accomplishing this goal, we need your input. Your responses are taken very seriously. Please take a few minutes to complete this anonymous form. . Name of Program: Outpatient Intensive Recovery F.S.T CSP I.T. DAE Other Are you or a family member attending treatment? How long have you been in the program? Male -or- Female | Age Ethnicity Language Referred by   1 I was offered an appointment in a timely manner. 2 Overall, I am satisfied with my treatment. 3 My counselor clearly explained my rights and the rules & polices of the clinic at the beginning of my treatment. 4 The staff members at the program are friendly and courteous to me. 5 The staff demonstrated an understanding of my racial and cultural background. 6 The staff and I work together as a team to meet my treatment goals. 7 If I needed help again, I would return to the program. 8 Sometimes the staff members seems so busy that I feel as though they don't have time for me. 9 I have confidence in myself and my abilities as a result of my experiences with the clinical staff. 10 I feel that the help available to me at the program is NOT meeting my needs. 11 I would refer my family and friends to the clinic if they needed help. 12 Staff is able to communicate with me in my language. 13 Do you feel as though you were given a choice of medications including alternatives to medications? 14 I have used the after hours on-call and found it helpful. 15 In the last 30 days, have you: (choose all that apply): Been to the emergency room Been hospitalized for a medical problem Been hospitalized for a emotional problem Been arrested None of the above Additional comments can be written here.
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