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Perception of Care Survey
In order to provide the best possible mental health, physical health and related services, we need to know what you think about the services you and/or your family received during the past 30 days. After answering the initial questions, please indicate your disagreement/agreement with each of the following statements.
Name of Client
First Name
Last Name
Client's Date of Birth (DOB)
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
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31
Day
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
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1931
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1928
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1926
1925
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1923
1922
1921
1920
Year
How are you related to the client?
*
I am the client.
I am the client's parent/guardian.
I am a family member completing the form for the client.
I am a provider completing the form for a client.
This questionnaire was completed by:
*
Administrative staff
Care coordinator
Case Manager
Clinician providing direct services
Consumer peer
Data collector
Evaluator
Family advocate
Research assistant staff
These are the services I and/or my child/family has participated in:
*
Individual Therapy
Care Management
Peer Services
Medication Management
Primary Care
Where is your service provider(s) located?
*
Syracuse area
Oneida area
Fulton area
Rochester area
How have you been participating in services?
*
My services are in person
My services are remote and not in person
My services are both remote and in person
How has your family been participating in services?
*
Services are in person
Services are remote and not in person
Services are both remote and in person
TECHNOLOGY
Strongly Disagree
Disagree
Undecided
Agree
Strongly Agree
Not Applicable
The details of how to attend telehealth sessions were clear before the date of my appointment.
If assistance was needed in attending telehealth appointments, I knew who to contact for help.
I knew what to do if the telehealth appointment abruptly ended.
ENVIRONMENT
Strongly Disagree
Disagree
Undecided
Agree
Strongly Agree
Not Applicable
The surroundings seemed clean.
I felt safe.
I felt welcomed.
The location was convenient.
PATIENT RIGHTS
Strongly Disgree
Disagree
Undecided
Agree
Strongly Agree
Not Applicable
Staff respected my family's religious/spiritual beliefs.
Staff were sensitive to my cultural background (race, religion, language, etc.).
I was given information about my rights.
I feel free to complain.
Staff respected my wishes about who is and who is not to be given information about my treatment.
My questions, concerns and complaints are responded to in a timely manner and resolved to my satisfaction.
PATIENT RIGHTS (child form)
Strongly Disgree
Disagree
Undecided
Agree
Strongly Agree
Not Applicable
Staff respected my family's religious/spiritual beliefs.
Staff were sensitive to my family's cultural background (race, religion, language, etc.).
I was given information about my rights.
I feel free to complain.
Staff respected my wishes about who is and who is not to be given information about my child's treatment.
My questions, concerns and complaints are responded to in a timely manner and resolved to my satisfaction.
CARE
Strongly Disgree
Disagree
Undecided
Agree
Strongly Agree
Not Applicable
Staff here treated me with respect.
Staff spoke with me in a way that I understood.
I helped to choose my services.
I helped to choose my treatment goals.
I participated in my treatment.
The people helping me stuck with me no matter what.
I felt I had someone to talk to when I was troubled.
I have been offered the opportunity to include my family in my treatment.
I know how to reach out if I am experiencing a mental health emergency.
I know how to reach out if I am experiencing a physical health emergency.
CARE (child form)
Strongly Disgree
Disagree
Undecided
Agree
Strongly Agree
Not Applicable
Staff here treated my family with respect.
Staff spoke with me in a way that I understood.
I helped to choose my child's services.
I helped to choose my child's treatment goals.
I participated in my child's treatment.
I felt my child had someone to talk to when he/she was troubled.
The people helping my child stuck with us no matter what.
I have been offered the opportunity to include my family in my treatment.
I know how to reach out if my child is experiencing a mental health emergency.
I know how to reach out if my child experiencing a physical health emergency.
OVERALL RATINGS
Strongly Disgree
Disagree
Undecided
Agree
Strongly Agree
Not Applicable
Overall, I am satisfied with the services received at Liberty Resources.
The services I received were right for me.
I got the help I wanted.
I got as much help as I needed.
OVERALL RATINGS (child form)
Strongly Disgree
Disagree
Undecided
Agree
Strongly Agree
Not Applicable
Overall, I am satisfied with the services received at Liberty Resources.
The services my child and/or family received were right for us.
My family got the help we wanted.
My family got as much help as we needed.
On a scale of 1-10, where 0 is the worst and 10 is the best, what number would you use to rate your services with Liberty Resources?
1
2
3
4
5
6
7
8
9
10
Worst
Best
1 is Worst, 10 is Best
Do you think you would benefit from extra support?
Yes
No
Please provide a number for us to reach you, so we can discuss what extra supports you are interested in.
-
Area Code
Phone Number
Please provide additional information that would be helpful:
Submit
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