Environment Of The Clinic

1 How well does TCW keep illegal drug activity away from the clinic?
1 2 3 4 5 6 7 (1= Worst rating 7=best rating)

2 Does the location of the clinic provide you with privacy and confidentiality?
1 2 3 4 5 6 7 (1= Worst rating 7=best rating)

Medication Procedures

3 The speed and length of the medication line is:
1 2 3 4 5 6 7 (1= Worst rating 7=best rating)

4Are the nurses usually friendly and considerate to you?
1 2 3 4 5 6 7 (1= Worst rating 7=best rating)

5 How satisfied are you with the services you receive from the nurse?
1 2 3 4 5 6 7 (1= Worst rating 7=best rating) es?

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Medical Services

6 Does the doctor put you at ease and make you feel comfortable during your visit?
1 2 3 4 5 6 7 (1= Worst rating 7=best rating)

7Does the doctor treat you with dignity and respect?
1 2 3 4 5 6 7 (1= Worst rating 7=best rating)

8 Overall, how satisfied are you with the services you receive from the doctor?
1 2 3 4 5 6 7 (1= Worst rating 7=best rating)

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Counseling Staff

9 Getting in touch with your counselor is:
1 2 3 4 5 6 7 (1= Worst rating 7=best rating)

10 How frequently do you meet with your counselor?
daily
2 or 3 times a week
1 time a week
2 or 3 times a month
1 time a month
less than 1 time a month

11What referrals have you requested?
HIV/AIDS team
Vocational services
Medical services
Psychiatric services
Groups
Nutritional services
Parent-child services
Psychological testing / services
other (please specify)

11a Was your counselor able to provide these referrals?
1 2 3 4 5 6 7 (1= Worst rating 7=best rating)

12 Is counseling helping you?
1 2 3 4 5 6 7 (1= Worst rating 7=best rating)

13 The confidentiality and privacy of your counseling sessions are:
1 2 3 4 5 6 7 (1= Worst rating 7=best rating)

14 Does your counselor treat you with dignity and respect?
1 2 3 4 5 6 7 (1= Worst rating 7=best rating)

15 Overall, how satisfied are you with the services your receive from your counselor?
1 2 3 4 5 6 7 (1= Worst rating 7=best rating)

16 Who is your counselor? (optional)

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Misc

17 The fee you pay for services is:
1 2 3 4 5 6 7 (1= Worst rating 7=best rating)

18 Would you be interested in other groups being offered at TCW?
Yes No

If so, what type of group would you be interested in:

19 How long have you been in methadone treatment total?
less than 3 months
3 months to 1 year
1 year to 3 years
3 years to 6 years
6 years to 9 years
9 years to 12 years
12 years to 18 years
18 years to 24 years
over 24 years

20 How did you find out about this program?
TV
Friend
Referral from another clinic
"Grapevine"
Family
Doctor
Phone book
TCW patient
Do not remember

21 If you knew someone with a substance abuse problem, would you refer he/ him to thisprogram for help?
Yes No

22 Overall, how satisfied are you with access to this program?
1 2 3 4 5 6 7 (1= Worst rating 7=best rating)

23 Overall, how satisfied are you with this program’s responsiveness to your concerns?
1 2 3 4 5 6 7 (1= Worst rating 7=best rating)

24 How could TCW improve its responsiveness to your concerns