Referral Worker Satisfaction Survey

Please take a few minutes to complete this survey on the quality of service we provide. We welcome your feedback and appreciate your honesty. With your help, we hope to improve services provided to our clients, families and referral agency.

	Excellent	Above Average	Average	Below Average	Poor	N/A
Satisfaction of services received.	Satisfaction of services received. Excellent	Satisfaction of services received. Above Average	Satisfaction of services received. Average	Satisfaction of services received. Below Average	Satisfaction of services received. Poor	Satisfaction of services received. N/A
Communication with LCYDC Staff as needed.	Communication with LCYDC Staff as needed. Excellent	Communication with LCYDC Staff as needed. Above Average	Communication with LCYDC Staff as needed. Average	Communication with LCYDC Staff as needed. Below Average	Communication with LCYDC Staff as needed. Poor	Communication with LCYDC Staff as needed. N/A
Availability of LCYDC Staff when needed.	Availability of LCYDC Staff when needed. Excellent	Availability of LCYDC Staff when needed. Above Average	Availability of LCYDC Staff when needed. Average	Availability of LCYDC Staff when needed. Below Average	Availability of LCYDC Staff when needed. Poor	Availability of LCYDC Staff when needed. N/A
New skills learned by client in care that will help in the future.	New skills learned by client in care that will help in the future. Excellent	New skills learned by client in care that will help in the future. Above Average	New skills learned by client in care that will help in the future. Average	New skills learned by client in care that will help in the future. Below Average	New skills learned by client in care that will help in the future. Poor	New skills learned by client in care that will help in the future. N/A
Opportunity to participate in treatment planning.	Opportunity to participate in treatment planning. Excellent	Opportunity to participate in treatment planning. Above Average	Opportunity to participate in treatment planning. Average	Opportunity to participate in treatment planning. Below Average	Opportunity to participate in treatment planning. Poor	Opportunity to participate in treatment planning. N/A
Ability to give input on services provided to client.	Ability to give input on services provided to client. Excellent	Ability to give input on services provided to client. Above Average	Ability to give input on services provided to client. Average	Ability to give input on services provided to client. Below Average	Ability to give input on services provided to client. Poor	Ability to give input on services provided to client. N/A
Client was informed of all rules and guidelines provided by LCYDC.	Client was informed of all rules and guidelines provided by LCYDC. Excellent	Client was informed of all rules and guidelines provided by LCYDC. Above Average	Client was informed of all rules and guidelines provided by LCYDC. Average	Client was informed of all rules and guidelines provided by LCYDC. Below Average	Client was informed of all rules and guidelines provided by LCYDC. Poor	Client was informed of all rules and guidelines provided by LCYDC. N/A
Safety of environment for the client at LCYDC.	Safety of environment for the client at LCYDC. Excellent	Safety of environment for the client at LCYDC. Above Average	Safety of environment for the client at LCYDC. Average	Safety of environment for the client at LCYDC. Below Average	Safety of environment for the client at LCYDC. Poor	Safety of environment for the client at LCYDC. N/A
Protection of privacy and confidentiality of client served at LCYDC.	Protection of privacy and confidentiality of client served at LCYDC. Excellent	Protection of privacy and confidentiality of client served at LCYDC. Above Average	Protection of privacy and confidentiality of client served at LCYDC. Average	Protection of privacy and confidentiality of client served at LCYDC. Below Average	Protection of privacy and confidentiality of client served at LCYDC. Poor	Protection of privacy and confidentiality of client served at LCYDC. N/A
Chances of referring another client to LCYDC.	Chances of referring another client to LCYDC. Excellent	Chances of referring another client to LCYDC. Above Average	Chances of referring another client to LCYDC. Average	Chances of referring another client to LCYDC. Below Average	Chances of referring another client to LCYDC. Poor	Chances of referring another client to LCYDC. N/A

Excellent

Above Average

Average

Below Average

Poor

N/A

Satisfaction of services received.

Satisfaction of services received. Excellent

Satisfaction of services received. Above Average

Satisfaction of services received. Average

Satisfaction of services received. Below Average

Satisfaction of services received. Poor

Satisfaction of services received. N/A

Communication with LCYDC Staff as needed.

Communication with LCYDC Staff as needed. Excellent

Communication with LCYDC Staff as needed. Above Average

Communication with LCYDC Staff as needed. Average

Communication with LCYDC Staff as needed. Below Average

Communication with LCYDC Staff as needed. Poor

Communication with LCYDC Staff as needed. N/A

Availability of LCYDC Staff when needed.

Availability of LCYDC Staff when needed. Excellent

Availability of LCYDC Staff when needed. Above Average

Availability of LCYDC Staff when needed. Average

Availability of LCYDC Staff when needed. Below Average

Availability of LCYDC Staff when needed. Poor

Availability of LCYDC Staff when needed. N/A

New skills learned by client in care that will help in the future.

New skills learned by client in care that will help in the future. Excellent

New skills learned by client in care that will help in the future. Above Average

New skills learned by client in care that will help in the future. Average

New skills learned by client in care that will help in the future. Below Average

New skills learned by client in care that will help in the future. Poor

New skills learned by client in care that will help in the future. N/A

Opportunity to participate in treatment planning.

Opportunity to participate in treatment planning. Excellent

Opportunity to participate in treatment planning. Above Average

Opportunity to participate in treatment planning. Average

Opportunity to participate in treatment planning. Below Average

Opportunity to participate in treatment planning. Poor

Opportunity to participate in treatment planning. N/A

Ability to give input on services provided to client.

Ability to give input on services provided to client. Excellent

Ability to give input on services provided to client. Above Average

Ability to give input on services provided to client. Average

Ability to give input on services provided to client. Below Average

Ability to give input on services provided to client. Poor

Ability to give input on services provided to client. N/A

Client was informed of all rules and guidelines provided by LCYDC.

Client was informed of all rules and guidelines provided by LCYDC. Excellent

Client was informed of all rules and guidelines provided by LCYDC. Above Average

Client was informed of all rules and guidelines provided by LCYDC. Average

Client was informed of all rules and guidelines provided by LCYDC. Below Average

Client was informed of all rules and guidelines provided by LCYDC. Poor

Client was informed of all rules and guidelines provided by LCYDC. N/A

Safety of environment for the client at LCYDC.

Safety of environment for the client at LCYDC. Excellent

Safety of environment for the client at LCYDC. Above Average

Safety of environment for the client at LCYDC. Average

Safety of environment for the client at LCYDC. Below Average

Safety of environment for the client at LCYDC. Poor

Safety of environment for the client at LCYDC. N/A

Protection of privacy and confidentiality of client served at LCYDC.

Protection of privacy and confidentiality of client served at LCYDC. Excellent

Protection of privacy and confidentiality of client served at LCYDC. Above Average

Protection of privacy and confidentiality of client served at LCYDC. Average

Protection of privacy and confidentiality of client served at LCYDC. Below Average

Protection of privacy and confidentiality of client served at LCYDC. Poor

Protection of privacy and confidentiality of client served at LCYDC. N/A

Chances of referring another client to LCYDC.

Chances of referring another client to LCYDC. Excellent

Chances of referring another client to LCYDC. Above Average

Chances of referring another client to LCYDC. Average

Chances of referring another client to LCYDC. Below Average

Chances of referring another client to LCYDC. Poor

Chances of referring another client to LCYDC. N/A

Referral Worker Satisfaction

1. Service Characteristics

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* 1. Please enter client's first and last name:

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* 2. Please specify program survey is being completed for:

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* 3. Select which county you are affliated with:

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* 4. Select which time frame survey is being completed for:

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* 5. Please rate the following questions.