Survey


YOUTH SERVICES SURVEY

Please help our agency make services better by answering some questions about the services you received OVER THE LAST 6 MONTHS. Your answers are confidential and will not influence the services you receive. Please indicate if you Strongly Disagree, Disagree, Are Undecided, Agree, or Strongly Agree with each of the statements below.

Please click the button next to the answer of your choice. Once you are done with this survey, please click "Finished" at the bottom of the page.

1. Please answer the following to let us know a little about you.

Gender

Male
Female


2. Age

0 to 12
13 to 17
18 to 20
21


3. Race

Chamorro
FSM
Palau
White
Asian
Pacific Island /Hawaiian
Black / African American
Mixed


4. Do you have Medicaid insurance?

Yes
No


5. For each item, circle the answer that matches your view:

1. Overall, I am satisfied with the services I received

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


6. I helped to choose my services

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


7. I helped to choose my treatment goals

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


8. The people helping me stuck with me no matter what

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


9. I felt I had someone to talk to when I was troubled

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


10. I participated in my own treatment

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


11. I received services that were right for me

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


12. The location of services was convenient

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


13. Services were available at times that were convenient for me

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


14. I got the help I wanted

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


15. I got as much help as I needed

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


16. Staff treated me with respect

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


17. Staff respected my family's religious/spiritual beliefs

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


18. Staff spoke with me in a way that I understood

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


19. Staff were sensitive to my cultural/ethnic background

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


20. As a Direct Result of Services I received:

I am better at handling daily life.

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


21. I get along better with family members.

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


22. I get along better with friends and other people.

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


23. I am doing better in school and/or work.

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


24. I am better able to cope when things go wrong.

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


25. I am satisfied with my family life right now.

Strongly Agree
Agree
Are Undecided
Disagree
Strongly Disagree


26. What has been the most helpful thing about the services you received over the last 6 months?




27. What would improve the services here?




28. Please answer the following questions to let us know how you are doing.

How long did you receive services from DMHSA?

Less than 1 month
1-2 months
3-5 months
6 months to 1 year
More than 1 year


29. Are you still getting services from DMHSA?

Yes
No


30. Are you currently living with one or both parents?

Yes
No


31. Have you lived in any of the following places in the last 6 months?

With one or both parents
With another family member
Foster home
Therapeutic foster home
Crisis shelter
Homeless shelter
Group home
Residential treatment center
Hospital
Local jail or


32. In the last year, did you see a medical doctor (nurse) for a health check up or because you were sick?

Yes, in a clinic or office
Yes, but only in a hospital emergency room
No
Do not remember


33. Are you on medication for emotional/behavioral problems?

Yes
No


34. If yes, did the doctor or nurse tell you what side effect to watch for?

Yes
No


35. In the last month, did you get arrested by the police?

Yes
No


36. 31. In the last month, did you go to court for something you did?

Yes
No


37. How often were you absent from school during the last month?

1 day or less
2 days
3 to 5 days
6 to 10 days
More than 10 days
Not applicable / not in school
Do not remember