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		Client Survey

			Please aide us in serving you better by checking the appropriate boxes in the survey questions below:
			Date (mm/dd/yyyy) Building 1. I feel / felt safe in the hospital. Yes No I Don't Know 2. The areas I observed during my stay were clean and properly maintained Yes No I Don't Know 3. I feel / felt free to express my opinions or concerns Yes No I Don't Know 4. This hospital stay is helping / has helped m to learn better coping skills Yes No I Don't Know 5. I am being / was treated with respect and dignity while in the hospital Yes No I Don't Know 6. I feel that I am on the road on to my recovery as a result of coming to the hospital Yes No I Don't Know 7. I am / was given the information I need(ed) about why I take medications. Yes No I Don't Know 8. I am/ was given the information I need(ed) about groups and activities that are available to me Yes No I Don't Know 9. I am / was an active participant in my treatment planning. Yes No I Don't Know 10. I am helping/ helped to develop my discharge / after care plan. Yes No I Don't Know 11. The hospital has helped me feel hopeful about my personal recovery. Yes No I Don't Know 12. I am / was given the information I need about my medications Yes No I Don't Know 13. I feel / felt safe in the hospital. Yes No I Don't Know 14. What activities have been/ were the most helpful? enter text The thing(s) I like/liked the most about the hospital: enter text The thing(s) I would like to change about the hospital: enter text The most helpful person or people were: enter text Please provide the following contact information: Name StreetAddress City State/Province Zip/ Postal Code Work Phone Email Please select from the following that best describes you:
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