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Menu
Referrals
Alliance Referral System
Send A Referral
Membership
Join The Alliance
Member Directory
Login
Membership FAQ’s
Accreditation
About Accreditation
Enhancing Credibility
Events
Event Calendar
Sheltered Conference
About Us
Who We Are
Public Reports & Press
Contact
Jobs
Work With Us
Job Board
Post A Job
Employer Dashboard
Get Involved
Join The Arbor
Request A Speaker
Church Partnership
Shop The Store
Donate
Give Monthly
One-Time Gift
Partnership Referral from a Former Individual Client
This form is a way for NTSA to evaluate the program you participated in, in order to ensure it is a good fit for other prospective participants. You may remain anonymous or choose not to fill out this form if you do not feel comfortable sharing your experiences. If you have any questions please reach out to membership@shelteredalliance.org.
Name
First
Last
This is not required, you may remain completely anonymous.
Can we follow up with you after this survey if necessary?
Yes
No
If yes, please write in the best way to contact for any follow-up questions:
Program you participated in:
What month/year did you complete the program?
Currently employed?
Yes
No
Currently in higher education?
Yes
No
Currently have independent housing?
Yes
No
Currently living sober?
Yes
No
Open-Ended Questions
What are three things the program did to prepare you for the program?
If you could change one thing about the program or give leadership one suggestion for improvement, what would it be?
What did the program do to allow you to share any feedback you had for the program? (good feedback or grievances you had)
Please Score 1-5
On a scale with 1 being strongly disagree and 5 being strongly agree.
I am satisfied with the services I received from this provider.
1 - strongly disagree
2 - disagree
3 - neutral
4 - agree
5 - strongly agree
I would come back to this program if I needed help again.
1 - strongly disagree
2 - disagree
3 - neutral
4 - agree
5 - strongly agree
I would recommend this provider to people I care about.
1 - strongly disagree
2 - disagree
3 - neutral
4 - agree
5 - strongly agree
This provider helped me to get help from other places and services.
1 - strongly disagree
2 - disagree
3 - neutral
4 - agree
5 - strongly agree
I felt heard by staff when I wanted to give feedback on the program or change my own recovery plan.
1 - strongly disagree
2 - disagree
3 - neutral
4 - agree
5 - strongly agree
I felt safe in the program with the staff, participants, and any other people affiliated with the program.
1 - strongly disagree
2 - disagree
3 - neutral
4 - agree
5 - strongly agree
My life has improved socially because of the program; (for example: the program helped me to have healthier community and relationships).
1 - strongly disagree
2 - disagree
3 - neutral
4 - agree
5 - strongly agree
My life has improved financially because of the program; (for example: I have stable housing, income, and can manage my own expenses, bills and savings).
1 - strongly disagree
2 - disagree
3 - neutral
4 - agree
5 - strongly agree
[my_acf_user_form field_group="12979"]
