Juvenile Court Client Satisfaction Survey

Please answer the following questions:

Are you a

Youth
Parent/Guardian

How long have you/your child been in this treatment program?

Less than 1 month
1 month or longer (Specify # of months)

How long have you/your child been on probation?

Less than 1 month
1-6 months
6-12 months
A year or more

Have you/your child left the program?

Yes--How many months ago
No

Which of the following activities have you/your child participated in through this program? (check all that apply)

Assessment
Individual Counseling
Group Counseling
Family Counseling

Which of the following types of offenses best describes what brought you/your child to the court?

Unruly/Truant
Domestic Violence
Drug Offense
Violence Offense (assault, robbery)
Property Offense (vandalism, theft, forgery, etc)
Sex Offense
Other (specify)

What is/was your/your child's drug of choice?

None
Alcohol
Marijuana (Pot)
Cocaine/Crack Cocaine
Amphetamines (speed/diet pills/uppers)
Depressant (downers/tranquilizers)
Hallucinogens (acid/PCP/mushrooms)
Inhalants (glue/rush/poppers/locker room)
Other (specify)

What is/was your/your child's second drug of choice?

None
Alcohol
Marijuana (Pot)
Cocaine/Crack Cocaine
Amphetamines (speed/diet pills/uppers)
Depressant (downers/tranquilizers)
Hallucinogens (acid/PCP/mushrooms)
Inhalants (glue/rush/poppers/locker room)
Other (specify)

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 that you have received so far?

Very happy
Somewhat happy
Somewhat unhappy
Very unhappy
Not sure

How motivated are you to succeed in this program?

Very motivated
Somewhat motivated
Not very motivated
Not at all motivated

How helpful has each of these been to your recovery:

 Very Helpful Somewhat Helpful Somewhat Not Helpful Not  Helpful 
Mental Health Screening
Primary Counselor
Support Staff
Group Activities
Homework Assignments
Peer Support
Family Support
Other
How satisfied are you with each of the following items?
 Very Satisfied Somewhat Satisfied Somewhat Not Satisfied Not  Satisfied
The Services in General
Relationship with the Primary Counselor
Your involvement with treatment planning
Response by counselor to questions
Response by counselor to phone calls
Length of the treatment program
Accuracy of appointments scheduling
Access to Therapist
Time of Sessions
Frequency of Sessions
Cost of Service
Access to Therapists
Other
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
Female

How old are you?

Under 9
9-14
15-19
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

What is your marital status?

Married/Life Partner
Not 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
Aged 6-12
Aged 13-18
Have no children 18 or under living in household

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