Client Survey Check one: New ClientCurrent ClientFormer ClientStakeholder 1 = Strongly Disagree | 2 = Disagree | 3 = Slightly Agree | 4 = Agree | 5 = Strongly Agree RGC provides services that are relevant to the needs of consumers. 12345 RGC staff responded to and addressed my/the consumer's needs promptly. 12345 RGC employees are respectful, ethical, and responsive to the needs of consumers, stakeholders. 12345 I feel confident that RGC provides consumers with appropriate, convenient, and individualized services. 12345 I would recommend/refer RGC services to others. 12345 What services would you like to see RGC provide in the future? How many days have you been absent from school/work in the last 90 days? How many discipline referrals have you had in the last 90 days? How many times have you been intoxicated in the last 90 days? How many angry outburst have you had in the last 90 days? Current employment status? Please rate your self esteem: 1=low, 5=high 12345 Please rate the quality of your relationships: 1=low, 5=high 12345 How would RGC improve current services? Would you like someone from RGC to contact you about this survey? YesNo If yes, please provide your name and phone number:
