FCIU Client Termination Satisfaction Survey

Thank you for taking the time to complete this survey. Your participation helps us to better serve you. Please be assured that your responses are anonymous.

Who initiated plans to proceed with terminating FCIU services?

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Who initiated plans to proceed with terminating FCIU services?

Therapist

Self

Both

Please indicate the severity of your family issues at the start of your treatment on a scale of 1 to 5 (1=minimal, 5=maximum)

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Please indicate the severity of your family issues at the start of your treatment on a scale of 1 to 5 (1=minimal, 5=maximum) (Select an Answer) 1 2 3 4 5

Please indicate the severity of your family issues at the conclusionof your treatment on a scale of 1 to 5 (1=minimal, 5=maximum)

 *

Please indicate the severity of your family issues at the conclusionof your treatment on a scale of 1 to 5 (1=minimal, 5=maximum) (Select an Answer) 1 2 3 4 5

Your status at closing (check all that apply)

Your status at closing (check all that apply)

Service goals were met

Referred for long term and/or specialized services

Moved out of the county

Declined further services

Dissatisfaction with services

Other (please specify) If other, type text here.

Your satisfaction with the plan at the conclusion of your treatment

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Your satisfaction with the plan at the conclusion of your treatment

Poor

Fair

Good

Very Good

Excellent

Your satisfaction with the quality of treatment at the FCIU

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Your satisfaction with the quality of treatment at the FCIU

Poor

Fair

Good

Very Good

Excellent

The likelihood that, if necessary, you would seek assistance from the FCIU in the future

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The likelihood that, if necessary, you would seek assistance from the FCIU in the future

Poor

Fair

Good

Very Good

Excellent

Please feel free to comment further on any aspect of your involvement with the FCIU

Please feel free to comment further on any aspect of your involvement with the FCIU

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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