Service Delivery Evaluation

*Client Number      *Staff use only

We invite you to provide feedback about your experience with our services and service provider.  Please read each statement below and select the number of the rating that matches your experience.  We appreciate your time and attention to providing important feedback.    

    Service Provided    Select One Outpatient Services In Home Family Based Services Adolescent or Child Treatment Program School Support Services

    County of Residence   

    TSA Staff      Select One Jon Butala Bethany Cleary Dave Duram Scott Emmons Sue Haugen Ben Hoogland Annette Huff Christine Johnson Cindi Johnson Penni Johnson Jonelle Klemz Beth Lake Jen Lawrence Deb Lindau Molly McHugh Jim Molberg Keela Niemeyer Bruce OLeary Kris Ostlund Kathy Points Linda Richnofsky Ellen Rollins Jen Rye Lisa Sater Teri Schilling Tom Staloch Lisa Tollefson Nate Vojtech Sandy Woolsey Amy Zins

How satisfied were you with:

 1.  Access to services including referral process at TSA?    Select One Very Satisfied Satisfied Neutral Dissatisfied Very Dissatisfied N/A

     1. Comments

2.  Understanding the treatment plan for your service experience?    Select One Very Satisfied Satisfied Neutral Dissatisfied Very Dissatisfied N/A

     2. Comments

3.  Communication between you and the TSA staff person?    Select One Very Satisfied Satisfied Neutral Dissatisfied Very Dissatisfied N/A

      3. Comments

4.  The service(s) provided by the TSA staff person?   Select One Very Satisfied Satisfied Neutral Dissatisfied Very Dissatisfied N/A

     4. Comments

5.  The progress that was made in addressing goal areas?    Select One Very Satisfied Satisfied Neutral Dissatisfied Very Dissatisfied N/A

     5. Comments

6.  The effects of services on other family members if applicable?    Select One Very Satisfied Satisfied Neutral Dissatisfied Very Dissatisfied N/A

     6.  Comments

7.  Feeling that services were provided sensitive to your culture?    Select One Very Satisfied Satisfied Neutral Dissatisfied Very Dissatisfied N/A

     7. Comments

8.  The development of a follow up plan.    Select One Very Satisfied Satisfied Neutral Dissatisfied Very Dissatisfied N/A

     8. Comments

Additional comments are welcome if you have more feedback to share: