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How long have you been aware that you are in need of residential services?
 
Less than 6 months
 
6 months to less than 1 year
 
1 year to less than 3 years
 
3 years to less than 5 years
 
5 years or more
 
 
How often do you use alcohol? Drugs? or any other mind and mood altering chemical?
Don't Use Daily Weekly Monthly Quarterly
Alcohol
Crack/Cocaine
Heroin/Methadone
Marijuana
Prescription Medication
 
 
 
Which of our services do you feel would help you best?
 
Faith-based structuring?
 
Critical Thinking Groups?
 
Individual Counseling?
 
Life Coaching?
 
Job Readiness training?
 
Motivational Seminars?
 
Other
 
 
 
 
Based upon your introduction to Rhama Word House. How confident are you with us?
 
Highly satisfied
 
Somewhat satisfied
 
Neutral
 
Somewhat dissatisfied
 
Highly dissatisfied
 
 
How do we rate on the following attributes?
Well Below Average Below Average Average Above Average Well Above Average
Knowledge
Access
Professionalism
Services offered
Quality of service
Understanding of customers' needs
 
 
 
How do we rate in comparison to other organizations that offer the same services?
 
Much higher
 
Somewhat higher
 
Same
 
Somewhat lower
 
Much lower
 
Don't know
 
 
 
How likely are you to tell others about Rhama Word House?
 
Very likely
 
Somewhat likely
 
Neutral
 
Somewhat unlikely
 
Very unlikely
 
 
 
Have you ever lived in a residential program before?
 
No,
 
Once or twice
 
More than twice
 
 
 
Do you have any fears of living in a residential program?
   
Are you on any form of medication that requires monitoring?
   
Have you had any mental illness which required physician treatment?
   
 
 
 
What is your religous beliefs?
 
Christianity
 
Other religion
 
Prefer not to answer
 
 
 
What is your age?
 
Younger than 18
 
18 - 24
 
25 - 34
 
35 - 44
 
45 - 54
 
55 - 64
 
65 or older
 
Prefer not to answer
 
 
 
What is your source of income?
 
Employed full-time
 
Employed part-time
 
Self-employed
 
SSI
 
Trust Fund
 
Student
 
Retired
 
Homemaker
 
Military
 
Prefer not to answer
 
Other
 
 
 
 
Which of the following categories best describes your annual income?
 
Under $15,000
 
$15,000 - $29,999
 
$30,000 - $44,999
 
$45,000 - $59,999
 
$60,000 - $74,999
 
$75,000 - $89,999
 
$90,000 or more
 
Prefer not to answer
 
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