Georgia Department of Family & Children Services System of Care: Support Services Unit Client Satisfaction Survey
Client Satisfaction Survey Instructions
Client Satisfaction Surveys should be given to all clients served
Complete for all Support Services program referrals
All providers are required to use the State Office issued survey form for mid-point surveys, and at the end of service
The agency must establish a protocol to obtain the client’s feedback that does not jeopardize the integrity of the answers provided by the client. All Results must be available to DFCS if an audit occurs. A copy of the written protocol should also be available for review during the DFCS audit.
Check one:
Mid-Point Service Review
End of Service/Exit Survey
Check here if client declines to complete the survey.
By printing their name and signing below, the client is affirming their right to not complete this survey.
Name:
Reset Signature
Client Signature:
Reset Signature
Click here in the event the client is unable to complete this survey by themselves, the client has the right to request assistance from a third party. The client must indicate “by marking their mark” giving consent for another individual to complete the satisfaction survey on their behalf.
Third party Name
Third party Signature
Reset Signature
Witness name
Agency name
Service Provided
Client first name
Client last name
Today's Date
Service Start Date
Service End Date
Ratings
0 = N/A
1 = Strongly Disagree
2 = Disagree
3 = Agree
4 = Strongly Agree
Provider began working with us within the first 2 business days of initial contact
0
1
2
3
4
Provider considered my family’s strengths and opinions
0
1
2
3
4
The time spent with my family before the Family Team Meeting (FTM) was helpful in preparing for the meeting
0
1
2
3
4
Provider was courteous and respectful
0
1
2
3
4
Provider kept appointments and was on time
0
1
2
3
4
Provider contacted me within 24 hours before appointments(s) to alert me to schedule changes and attempted to reschedule appointment(s) at a time that was convenient for my family
0
1
2
3
4
Provider worked with my family in a crisis and was helpful calming the situation
0
1
2
3
4
Transportation services were dependable and on time
0
1
2
3
4
The materials and skills shared were helpful to achieve my case plan
0
1
2
3
4
I feel the provider communicated my family’s strengths and needs clearly to DFCS
0
1
2
3
4
I have gained knowledge and/or skills by participating in this program
0
1
2
3
4
Provider gave me a name of a contact person to express my concerns and/or issues with their customer service
0
1
2
3
4
What are the skills you learned from this program that are useful to you?
How will you apply the skills you learned in this program?
How will you apply the skills you learned in this program?
What are some skills you currently use that will be discontinued as a result of participating in this program?
What changes or suggestions would you recommend regarding this program?
Additional Comments: