Family Connections
Client Survey

Client Name *

Consellor Name (Who helped you?) *

File Discharge Date *

I was given written information about client rights and responsibilities. * YesNoSomewhat

The people who work at LCSS treat me with respect and courtesy. * YesNoSomewhat

The staff is respectful about my confidentiality and privacy. * YesNoSomewhat

I was given a Complaint Procedure form. I know where to go at LCSS or whom to speak to if I have a complaint. * YesNoSomewhat

LCSS asks me about my ideas on how to improve its services. * YesNoSomewhat

Accessibility: LCSS is easy for me to get to with regard to access to transit, free parking, and wheelchair accessibility and general location. **** OR the Outreach worker comes to my home. * YesNoSomewhat

LCSS services are available at times that are good for me. * YesNoSomewhat

LCSS’ building and offices are clean. * YesNoSomewhat

I feel safe while at LCSS and on LCSS property. * YesNoSomewhat

I help plan my services and set my goals. * YesNoSomewhat

I was able to receive services from LCSS without waiting too long. * YesNoSomewhat

I would recommend LCSS to my family and friends. * YesNoSomewhat

If I needed help or services again I would come back to LCSS. * YesNoSomewhat

Overall, I am satisfied with the services I am receiving. * YesNoSomewhat

I provide a safe and appropriate environment for my children. * YesNoSomewhat

I have increased my knowledge of parenting skills. * YesNoSomewhat

Additional Comments