Holistic & Multicultural Counseling Services

Patient Advocate/Quality Assurance

Group Of Children Playing In Park

We value your services and encourage you to share your feedback with us. This survey will go directly to the management personnel, not to the employee serving you.

Survey forms are conveniently located within the web page. Please fill in with details and click on tap to answer the question on this survey

This is an opportunity for you to help us to services best. You can call us anytime to let us know if our staff or service fits your needs.

If your safety or quality of care concern has not been addressed to your satisfaction, or if you prefer management personnel, contact HR Quality Assurance officer at 781 885-7252.

Please fill out our questionnaire:


Service Satisfaction Survey

*Red indicates a required field

*Name of person being served

*Name of Person completing survey

Relationship of person completing survey to person being served

*Phone of person completing survey


*Email of person completing survey


Start of Services:

End of Services:

Which program did you receive services from?

Name of Insurance Carrier:

ID number:

If you received services from the Youth Development Early Learning Center (Youth DELC), what method of payment does patient have?

Name of Other payer:

If paid for by a state agency, which of the following?

We require that this short survey should be completed no less than twice from the time we start working with you, within week’s services and three weeks before services end. If your treatment or quality of care concern has not been addressed to your satisfaction, or if you prefer management personnel, contact Quality Assurance Department at 781 885-7252 at Extension O.

Services / Programs

How would you rate our services based on the following:
1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent

How would you rate our services?

Do you feel that our services were beneficial?

Did our services fulfill your needs?

Was our model what you were looking for?

Was the schedule convenient for you?

In your own words, how would you describe your overall interactions with our services?

How would you rate our service’s ability to work with other service providers that work with you and your family (Examples: School Staff, DMH, DCF, DYS, EEC, ICC, Probation, Primary Care Doctor, Outpatient Therapist, Etc.)?

How would you rate our service’s ability to connect you with the resources that you, your child or your family needed (Example: Vouchers)?

Were we able to help you reach your goals in the services we offered?

If No, how could we have better helped you?

Were our treatment interventions culturally relevant to you and your family?

Were our service professionals culturally relevant to you and your family?

Have you been using DBT?

Which four DBT skill modules are being learned?

How has it been helpful to you and your family?

Is there any other important information that you would like to share with us?

Additional Notes:

Professional Staff in Program

How would you rate your Professional in program, based on the following:
1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent

Punctuality:

Valuable:

Enthusiasm:

Activities:

Goals accomplished:

What days did you meet?

What times did you meet?

In your own words, how would you describe your interaction with your clinician?

Additional Notes:

Administrative or other Staff Assisting

How would you rate your services based on the following:
1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent

Punctuality:

Valuable:

Enthusiasm:

Activities:

Goals accomplished:

What days did you meet?

What times did you meet?

In your own words, how would you describe your interactions with your mentor or community support provider?

Additional Notes:

Parent Engagement / Group Support Services

How would you rate your Group facilitators based on the following:
1 = Poor 2 = Fair 3 = Good 4 = Very Good 5 = Excellent

Punctuality:

Valuable:

Enthusiasm:

Activities:

Goals accomplished:

What days did you meet?

What times did you meet?

In your own words, how would you describe your interactions with your mentor or community support provider?

Additional Notes:

captcha