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The Consumer Satisfaction Team, Inc.

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(English) Community Outreach Survey

CST would like your feedback regarding the behavioral health services that you or your loved one is receiving as well as ascertain your knowledge on resources that are made available through DBHIDS. Please take a few minutes to fill out and return this form.

1) What is your zip code?

2) How would you describe yourself?

An individual receiving behavioral health services (Mental Health and/or Substance Use Services)

A family member/loved one of someone receiving behavioral health services (Mental Health and/or Substance Use Services)

None of the above

**Name of Agency where you/your loved one is receiving services

3) What type of BH services do you or your family member/loved one receive?

Adult Mental Health (MH)

Substance Use (SU)

Child/Adolescent Services

Dual//Co-Occurring (MH/SU)

4) Has the quality of your/your loved one’s life improved since receiving services?

Yes

No

(if yes) Please explain:

5) Are you encouraged to provide feedback about the BH services you or your loved one is receiving?

Yes

No

If so, how?

Via phone

Attend meetings

Third ChoiceFill out surveys

Other

6) Is there a location in your community that offers assistance to obtain needed resources in your community?

Yes

No

If yes, circle all that apply:

Church

Community Center

School

Health Care Center

Police Station

Food Bank

Library

Support Groups

Other

7) What do you feel should be done to improve your physical environment?

Increased police presence

Renovation done on abandoned/neglected properties

Access to city officials

Active Civic Association

Town Watch

Cleaner streets

Other

8) What is most needed/important for you and your family to improve the quality of your life/lives?

Safe environment

Quality schools/activities for youth

Better paying jobs/job training

Access to affordable and healthy food

Access to affordable and safe housing

Information regarding free/low cost social activities

Access to affordable and quality health care

Other

9) Has the DBHIDS assisted you in any way to improve the quality of you or your family’s life?

Yes

No

(if yes) Please explain:

Optional: If you would like CST to contact you to speak more about your behavioral health services/concerns please provide:

Name

Phone

The Consumer Satisfaction Team, Inc.

520 N. Delaware Ave., 7th Floor
Philadelphia, PA 19123
Phone (215) 923-9627

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