MOPS AOD Referral Source Survey

Please answer the following questions:

Overall, how helpful do you think this program has been?

1 - None at All
2 - Very Little
3 - Some
4 - Quite a bit
5 - A Lot

Overall, how happy are you with the services provided by this program?

Very happy
Somewhat happy
Somewhat unhappy
Very unhappy
Not sure

Did the MOPS Substance Abuse Program make your job easier?

1 - None at All
2 - Very Little
3 - Some
4 - Quite a bit
5 - A Lot

Overall, did the MOPS Substance Abuse Program meet the needs of the people you referred to the program?

1 - None at All
2 - Very Little
3 - Some
4 - Quite a bit
5 - A Lot

How helpful has each of these been:

 Very Helpful Somewhat Helpful Somewhat Not Helpful Not  Helpful 
Substance Abuse Screening
Primary Counselor
Support Staff
Group Activities
Homework Assignments
Treatment Summaries
Informal Consultation
Other
How satisfied are you with each of the following items?
 Very Satisfied Somewhat Satisfied Somewhat Not Satisfied Not  Satisfied
The Services in General
The referral process
Relationship with the Primary Counselor
Relationship with the Secondary Counselor
Your involvement with treatment planning
Response by staff to questions
Response by staff to phone calls
Length of the treatment program
Accuracy of appointments scheduling
Feedback about clients
Access to Therapist
Time of Sessions
Cost of Service
Other
What would make this experience more helpful? What would need to be different?
What could be done to make Mid-Ohio Psychological Services 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 best describes your work setting?
Criminal Justice
Mental Health
Children's Services
Church
Medical
Other

What best describes your position?

Line Worker
Middle Management
Director/Executive/Independent Professional

What is your gender?

Male
Female

How old are you?

20 - 29
30 - 39
40 - 49
50 - 59
60+

Which of the following best represents the highest level of education that you have completed?

Some high school or less
High school graduate
Attended some college
Associates degree
Bachelors degree
Post-college graduate

With which of the following groups do you most identify?

African-American/Black
Asian-American or Pacific Islander
Hispanic/Latino
Native American
White
Other

Which of the following best describes your income in the past 12 months?

Under $10,000
$10,000 - $29,999
$30,000 - $59,999
$60,000 - $79,999
$80,000 +

Contact Information
This section is optional. Please fill out this section only if you would like us to get in touch with you.

First Name
Last Name
Address 1
Address 2
City
State
Zip / Postal Code
Home Phone
Work Phone
E-mail
Fax
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Last modified: April 10, 2008


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Last modified: April 10, 2008