Community Stakeholder Survey
Freedom Healthcare, LLC Community Wellness Center
Contact Information
Full Name
*
Email Address
*
Cultural Information
Race/Ethnicity
*
Select Race/Ethnicity
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Two or More Races
Prefer not to say
Age
*
Select Age Range
18-24
25-34
35-44
45-54
55-64
65+
Gender
*
Select Gender
Male
Female
Non-binary
Prefer not to say
Relationships
Number of years you have known about this organization
*
Select Duration
Less than 1 year
1–3 years
4–6 years
7–10 years
More than 10 years
Are you employed in an organization that refers persons to our services?
*
Yes
No
Relationship with persons who have participated in our services
*
I have, or have had, a family member, friend, acquaintance, or professional client who has participated in your services.
I have not had a direct relationship with anyone who has participated in your services.
Survey Questions
Rating Scale:
1
= Disagree Strongly |
2
= Disagree |
3
= Disagree Slightly |
4
= Agree Slightly |
5
= Agree |
6
= Agree Strongly |
7
= N/A
1.
When contacting us by phone, your call is answered in a prompt and courteous manner.
1
(Disagree Strongly)
2
3
4
5
6
7
(N/A)
2.
Our employees return phone calls and/or answer email messages in a timely manner.
1
(Disagree Strongly)
2
3
4
5
6
7
(N/A)
3.
Requests for information about our services, or about an individual receiving services, are responded to in a timely manner.
1
(Disagree Strongly)
2
3
4
5
6
7
(N/A)
4.
I have been treated with respect each time I have had contact with your organization.
1
(Disagree Strongly)
2
3
4
5
6
7
(N/A)
5.
Persons who request services, and meet the requirements for admission to a program, are admitted in a timely manner.
1
(Disagree Strongly)
2
3
4
5
6
7
(N/A)
6.
Our organization treats all persons participating in services with respect.
1
(Disagree Strongly)
2
3
4
5
6
7
(N/A)
7.
Our employees are sensitive to differences in the cultural backgrounds of the persons receiving services.
1
(Disagree Strongly)
2
3
4
5
6
7
(N/A)
8.
Our organization encourages, and is open to feedback about the quality of our services.
1
(Disagree Strongly)
2
3
4
5
6
7
(N/A)
9.
Our organization is highly respected throughout the community for providing quality services.
1
(Disagree Strongly)
2
3
4
5
6
7
(N/A)
10.
I would recommend your organization's services to a family member or friend, without hesitation.
1
(Disagree Strongly)
2
3
4
5
6
7
(N/A)
11.
Accessibility to the program meets my expectations. (Please provide details in the comments section below.)
1
(Disagree Strongly)
2
3
4
5
6
7
(N/A)
Additional Comments
Please provide any specific suggestions you may have for improving our organization and our services:
Please provide any additional comments you may have related to your experience with our organization:
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