My B.R.O.T.H.E.R.S House, Inc.

4822 Albemarle Suite 105

Charlotte, NC 28215
(704)532-4770
(704)532-4774 Fax

CUSTOMER SERVICE SURVEY RESPONSE

Date: ____________

Grading Scale
1.Poor 2.Needs Improvement 3.Fair
4.Good 5.Excellent

Questions (Please use grading scale above)

__1. How would you rate the sanitation and upkeep of M.B.H facilities?
__2. Does MBH staff/personal communicate weekly progress with you regarding the consumer(s)
by fax, telephone written documentation, etc? Yes/No (Please Rate)
__3. Does MBH personnel provide adequate treatment and supervision for consumer(s)? Yes/No
(Please Rate)
__4. How would you rate the competency level of the supervisor/staff?
__5. Is proper notification for staffing done with (2) week’s notice for parent/legal guardian and
case manager, how would you rate the level of professionalism within this company?
__6. As parent/legal guardian/case manager, how would you rate the level of professionalism within
this company?
__7. Does MBH, Inc. make you feel a part of the treatment team when staffings are taking place?
Yes/No (Please Rate)
__8. Would MBH be a place of recommendation to other agencies or families in need? Yes/No
(Please Rate)
__9. How would you rate the overall level of services offered at MBH Inc?

Comments:
_____________________________________________________________________________________
_____________________________________________________________________________________

Circle One:
Parent (P) Legal Guardian (LG) Case Manager (CM) Probation Officer (PO)

Area Program (Please check which one applies):

Meck-Link () Coastalcare () Smoky Mountain Center Alliance Behavioral Health ()
Partners Behavioral () Eastepointe()

Other:_______________________

DSS:________________________

Revised 5/21/13