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Questions marked with a * are required Exit Survey
 
Contact Information
First Name : 
Last Name : 
Phone : 
Email Address : 
 
 
 
* Which services did you access while at our agency?
 
Individual counseling/therapy
 
Anger management group
 
Couples Counseling
 
Psychological testing
 
Therapeutic mentoring

 
 
 
Highest level of education?
 
HS
 
Some College
 
Certificate
 
Bachelors
 
Masters
 
Doctorate
 
 
 
Annual Salary
 
0-24k
 
25k - 44k
 
45k - 64k
 
65k+
 
 
 
Age?
 
18 - 24
 
25 - 34
 
35 - 44
 
45 - 54
 
55 +
 
 
 
How would you rate our services?
 
Poor
 
Average
 
Above average
 
Excellent
 
 
 
* Would you refer a friend or family member to our agency?
 
Yes
 
No
 
 
 
How did you hear about us?
 
Friend/family
 
Website
 
Other agency
 
Flyer
 
Facebook
 
 
 
Do you feel you were treated with respect while receiving services at our agency?
 
Yes
 
No
 
 
 
Were you offered the opportunity to help develop your treatment goals?
 
Yes
 
No