MARIN TREATMENT CENTER -- ABOUT US

TO: MTC Clients FROM: Brian Slattery, Executive Director SUBJECT: Satisfaction Survey We are interested in your feedback and suggestions for program improvement. Feel free to skip any questions you don't want to answer. Please Submit to us using the button at the bottom of the screen.


1. TREATMENT PROGRAM:
Treatment:	Maintenance: Detox (21-Day Program) : Counseling Only :
How long have you been in treatment at MTC?
How long has it been since you were in treatment at MTC?
2. DEMOGRAPHICS (Optional):
Age :
Gender (Circle One) :	Male Female Transgender
Sexual Orientation :
Race/Ethnicity :
3. PLEASE RATE THE FOLLOWING MTC SERVICES THAT YOU HAVE RECEIVED (Circle) :
OVERALL QUALITY OF CARE :	Not Applicable Poor Fair Satisfactory Good Excellent
COUNSELING SERVICES :	Not Applicable Poor Fair Satisfactory Good Excellent
MEDICAL SERVICES :	Not Applicable Poor Fair Satisfactory Good Excellent
ADMINISTRATIVE SERVICES :	Not Applicable Poor Fair Satisfactory Good Excellent
Which HCV services have you received at MTC?	Information & Education Testing & Labs Referral for Treatment Coordination of Treatment HCV Evaluation & Treatment, if recommended

Have you taken Interferon for HCV?	Yes No
Did you complete treatment?	Yes No
Did treatment work?	Yes No
What health problems are of major concern to you personally ?	Hepatitis HIV Alcohol Cancer Heart Disease Mental Health Tobacco
What do you like best about the services you are receiving ? :

What do you like least about the services you are receiving :

What suggestions do you have for improving MTC's services?

Please add any additional comments