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Please answer the following questions:
How long have you been abstaining from alcohol and street drugs? I have not been abstaining [Click here if you selected this choice]
How long have you been actively working a program of recovery? I have not been actively working a program of recovery [Click here if you selected this choice]
How long have you been in this treatment program? Less than 1 month Yes--How many months ago
What is/was your drug of choice? Alcohol
What is/was your second drug of choice? None
Overall, how helpful do you think this program has been to you? Please use a scale of 1 to 5 where 1 means "none at all" and 5 means "a lot". 1 - None at All
Overall, how happy are you with the services that you have received so far? Very happy
How motivated are you to succeed in this program? Very motivated
How helpful has each of these been to your recovery:
What would make this experience more helpful? What would need to be different? What could be done to make this agency a better place to receive services? Demographics Please provide the following demographic information. It will only be used to make statistical comparisons between different groups of respondents; it will not be used to profile individual respondents. What is your gender? Male Under 20 years
Which of the following best represents the highest level of education that you have completed? Some high school or less Married
What are the age ranges of any children 18 years of age or younger living in your household? Choose all that apply. Under Age 6 years
With which of the following groups do you most identify? African-American/Black
Which of the following best describes your income in the past 12 months? Under $10,000
Contact Information
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