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AI AVENUES OF INDEPENDENCE


Client Feedback Form


* Indicates field is required.
First Name *
Year of Birth *
Month of Admission / Case Manager *

How much do you agree or disagree with the following statements about the treatment/services you received?
Please select the best answer below:
1 - Strongly Disagree
2 - Disagree
3 - Neither agree or disagree
4 - Agree
5 - Strongly Agree

The staff were properly trained and qualified with adequate understanding and knowledge of my needs. 1 2 3 4 5
The staff provided with me a copy of agency policies & procedures; Department of Mental Health Patients' Rights Information and internal grievance procedures and explained them to me in a way that I undestood. 1 2 3 4 5
Agency's indoor and outdoor living environment was safe, comfortable, clean and welcoming. 1 2 3 4 5
The Agency provided support services, which included toiletries; clean linen and towels; access to "free" laundry facilities and clothing options as needed. 1 2 3 4 5
The Agency provided three balanced meals(two of the three were hot). 1 2 3 4 5
The staff were sensitive to my cultural background, language and/or religious needs. 1 2 3 4 5
I was allowed to leave the facility at any time except after the set curfew hour. 1 2 3 4 5
I was provided with storage space for personal belongings and had access to to my medication when needed. 1 2 3 4 5
The Agency provided a minimum of 4 visiting hours a day. 1 2 3 4 5
My mail was given to me unopened. 1 2 3 4 5
I was given basic support services and information to resources such as housing, employment, education, recovery programs, vocational training and social activities. 1 2 3 4 5
Overall, I was satisfied with the treatment/services that I received. 1 2 3 4 5
I would recommend this shelter to others. 1 2 3 4 5

Essential Documents/Savings Obtained during your stay in the shelter :

TB Test
CA ID or CA DL
Social Security Card
Birth Certificate
GED Preparation/Course Enrollment OR Copy of High School Diploma
Resume/Cover Letter
Checkings or Savings Account
GR/Food Stamps

Additional service needs upon discharge :

Are you still in need of additional assisstance?     Yes   No
If yes, please specify by checking below :
Permanent Housing
Employment
Medical/Dental
Other


Comments :

Did anyone assist you with completing this form?
Please check either :Yes   No

Thank You



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Address: P.O. Box 561706, Los Angeles, CA, 90056   |   Phone: (323) 348-4109   |  Email: info@avenuesofindependence.org

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