Cyega Consumer SURVEY

Name

(Consumer’s name If more than one please write all of them)

Date

Welcome to Cyega Consumer SURVEY! First and foremost, we thank you for taking the time out of your busy schedule to help us improve our services. Here at Cyega, we value each and every one of our clients and we want to make sure our staff is providing the best service to our consumers. We thank you in advance for your honesty in regards to our questionnaires and for helping us to improve our services!

Please select the following response in regards to the questions asked. Please circle your responses. 1= strongly agree, 2= agree, 3= disagree

1. Professionalism of your Case Manager/ Therapist example (Is your CSI/Therapist polite, friendly, etc)? *

Strongly Agree

Agree

Disaree

2. Punctuality of your Case Manager /Therapist (Does your counseling representative arrive on time to scheduled appointments? *

Strongly Agree

Agree

Disagree

3. Does your Case Manager/Therapist speak about in-appropriate business such as agency issues, payroll, or personal business etc? *

Strongly Agree

Agree

Disagree

4. Is the client’s behavior improving in a positive direction? Example (Do you see improvement in the clients attitude, behavior, etc? *

Strongly Agree

Agree

Disagree

5. As an agency, what area would you like your counseling team to improve on that is not being addressed? Please write your responses in the lines below: *

6. How efficient is in house administrative team at answering your questions? Ex. Do they return calls in an appropriate amount of time, friendliness, ability to solve problems etc.? *

Very Efficient

Option 2

Not- Efficient

7. Do you feel our counseling service is beneficial for the client who is receiving services? *

Strongly Agree

Option 2

Disagree

8. Would you recommend our agency to others who might be struggling with behavior, depression, mental health etc problems? *

Strongly Agree

Agree

Disagree

9. Overall, how would you rate your Case Manager/ Therapist?( 1= Best, 2= moderate, 3= ok, 4= Not Beneficial, 5= Would like re-assignment of the current CSI/Therapist *

10. Additional comment section:

11. Frequency of clinician visits, how often do you see your clinicians weekly and monthly? Please give an average for the time period of services

Weekly - 8-10 visits monthly - Consistent

Biweekly - 2-4 Visits monthly - Not- Consistent

Monthly - 1-2 visits monthly - Extremely Not Consistent

Thank you for taking the time to fill out this questionnaire in regards to your counseling team. If you ever have any questions in regards to your counseling team, please feel free to call our 24 hour on call clinician at 281-936-0047 and asked to speak to a office manager!

Survey Completed By: *

(Consumer/ Parent or Guardian)

Date

Case Manager: *

(Please state the name of your Case Manager)

Cyega Consumer SURVEY

Referral

Online Referral Form