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Community Outreach Survey (English)

CST would like your feedback regarding the behavioral health services that you or your loved one is receiving, as well as, what resources you feel are needed to help improve the overall quality of you/your family’s life? Please take a few minutes to fill out and return this form. Thank you!

1. What is your zip code?

2. How would you describe yourself: (Please check one)

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 (Skip to Question # 7)

**Name of Agency where you are receiving services:

**Name of Agency where your loved one is receiving services:

3. What type of behavioral health 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)

Not Sure

No Response

4. Are you involved in your/your loved one’s treatment?

Yes

Sometimes

No

No Response

If so, how?

Via phone

Attend meetings

Fill out surveys

Video platform (i.e., Zoom, Google Meet, etc.)

Other:

Other

5. Has the quality of your/your loved one’s life improved since receiving behavioral health services?

Yes

A little/Somewhat

No

No Response

Please explain:

6. Do you feel that additional behavioral health services are needed to help improve the overall quality of your/your loved one’s life?

Yes

No

No Response

If yes, please explain:

7. Are you aware of a location in your community that offers assistance with obtaining needed resources?

Yes

No

Not Sure

No Response

If yes, please check all that apply:

Church

Recreation/Community Center

Local School

Health Care Center

Police Station

Food Pantry

Library

Support Groups

City Council Offices

Other

Other

8. What do you feel is needed/most important to improve the quality of you/your family’s life?

Please check all that apply:

Increase in police presence

Renovations on abandoned/neglected properties

Access to City Officials

Town Watch

Cleaner Streets

Quality schools/activities for youth

Access to healthy food

Better paying jobs/job training

Access to affordable housing

Access to affordable health care

Information on free/low-cost social activities

Other:

Other

9. Have you had any interactions with the Philadelphia Department of Behavioral Health and Intellectual disAbility Services (DBHIDS)?

Yes

No

Not Sure

No Response

If yes, how would you describe your experience? Please explain:

Additional Notes/Comments:

Name

This field is for validation purposes and should be left unchanged.

The Consumer Satisfaction Team, Inc.

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

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