Community survey for the Jewish Family Service Agency, 1980s

Please answer each of the following questions by filling in the appropriate information. Age : Sex: Male Female Marital Status: Single Separated Divorced Widowed Marr ied Do you have children Ages Number 0-15 15-21 over 21 How many years have you lived in the Las Vegas area? Are you affiliated with a religious organization? Synagogue or Church Yes NO Education: (circle highest level) Grade School High School Some College or Trade School Bachelor's Degree (or equivalent) Master's Degree (or equivalent) Ph.D.r M.D., etc. Zip Code of residence How were you referred to the agency? When you called the agency for information was your conversation informative and cordial? ;>> Yes No If an appointment was scheduled did your session start on time? Yes No Did you have difficulty in locating or reaching the agency Yes (if yes , explain) No Did the individual with whom you yjrS-TireH understand and , assist you with your problem? Yes No Were you referred to another Social Service Agency? Yes No If yes, did the referral source meet your needs? Yes No Were subsequent appointments scheduled at the agency? Yes No Was an appropriate arrangement made to handle fees? Yes No 9 . Please check off those services you requested from the Agency and evaluate each of them. EVALUATION SCALE 1. Excellent 2. Good 3. Satisfactory 4. Fair 5. Poor Counseling Who was Adult Child Parents Marital' the individual needing counseling? Adolescent _Life Supportive Services .Transportation _Home Caring Assistance _Shopping _Financial Assistance _Medical/Psychiatr ic aftercare _Immigrat ion _Adoption Service _Big Brother .Housing Information