TO: Former MTC Clients
FROM: Brian Slattery, Executive Director
SUBJECT: Satisfaction Survey
We are interested in your feedback and suggestions for program improvement. Please print out and complete the survey below to let us know your concerns. Feel free to skip any questions you don't want to answer. There is no need to sign or place your client number on this form unless you wish to. Mail to us at: 1466 Lincoln Avenue, San Rafael, CA 94901.
1. TREATMENT PROGRAM:
______Maintenance ______Detox (21-Day Program) ______Counseling Only
How long have you been in treatment at MTC? ________________________________________________
How long has it been since you were in treatment at MTC? ______________________________________
2. DEMOGRAPHICS (Optional):
Age:______ Gender (Circle One): Male Female Transgender
Sexual Orientation:__________________________ Race/Ethnicity: _______________________________
3. PLEASE RATE THE FOLLOWING MTC SERVICES THAT YOU HAVE RECEIVED (Circle):
Not Applicable Poor Fair Satisfactory Good Excellent
OVERALL QUALITY OF CARE N/A 1 2 3 4 5
COUNSELING SERVICES N/A 1 2 3 4 5
MEDICAL SERVICES N/A 1 2 3 4 5
ADMINISTRATIVE SERVICES N/A 1 2 3 4 5
Which HCV services have you received at MTC?
______Information & Education ______Testing & Labs ______Referral for Treatment
______Coordination of Treatment ______HCV Evaluation & Treatment, if recommended
Have you taken Interferon for HCV?______ Did you complete treatment? ______
Did treatment work?______
What health problems are of major concern to you personally?
______Hepatitis ______HIV ______Alcohol ______Cancer
______Eating Disorder ______Heart Disease ______Mental Health ______Tobacco
What do you liek best about the services you are receiving?
________________________________________________________________________________
________________________________________________________________________________
What do you like least about the services you are receiving:
________________________________________________________________________________
________________________________________________________________________________
What suggestions do you have for improving MTC's services?
________________________________________________________________________________
________________________________________________________________________________
Please add any additional comments
