This survey is to be completed at the end of all services at the agency. Please note that all required answers are marked as “Agree” by default. Please click on your answer if you wish to change the response. Once you are finished completing the survey, click on Submit.

Who is completing survey:

Services Provided: (Please check all that apply)

SECTION A – Involvement in Service Planning and Delivery

1. When I started services, the worker explained what was involved in receiving help from FYS and the treatment I would be receiving.

2. I was involved in identifying my strengths and my needs.

3. I participated in developing my treatment goals.

4. We reviewed my progress and I received feedback.

5. My worker listened to my concerns, opinions and wishes.

6. My worker understood and respected my culture and values.

7. The time I waited for service was reasonable.

SECTION B – Changes as a Result of Services

8. My need for counselling decreased over time.

9. Goals established for you/your family were achieved.

10. I felt positive about the outcome of treatment.

11. The service plan addressed all my identified needs.

SECTION C – Involvement in Service Planning and Delivery

How involved were you in:

12. Identifying strengths and needs for service.

13. Providing input for goals/agreeing on goals and outcomes.

14. Being kept informed about the status/success of service plans.

15. Determining readiness for discharge.

SECTION D – Degree to Which Services Were Comprehensive and Coordinated

16. How well were services coordinated with other agencies, if necessary.

17. How well did the agency communicate with you and others (school, physician etc.) regarding your services and planning.

SECTION E – Reasons for Ending Service

Please Check all Reasons for Ending your Service with Frontenac that Apply to your situation.

SECTION F – Status at Discharge

Please Check all that Apply to your situation.

Durham Region's Crisis Response line can be reached by calling 905-666-0483 or 1-800-742-1890 Learn about the Durham Region Crisis Line
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