North Cottage Program, Inc.

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Survey

The following survey is for former North Cottage Program clients. We are interested in your overall impressions of the experience at NCP as well as learning about your life since leaving the program. This is an anonymous survey although you are welcome to leave your first name with last initial only. Feedback is an important tool and helps us to know what we're doing right and where we can improve. We invite you to be a part of that process.

E-mail address optional:

Your name with last initial only:

Today's date is:

The date you left North Cottage. Please include the day, month, and year:

What is your current substance abuse status:

Are you alcohol free? Yes No

Date of last use:

Are you drug free? Yes No

Date of last use:

What is your housing status?

House Apartment Room Shelter Sober House Grad House Homless

Other

What is your employment status?

Employed Seeking Employment School Volunteer Work Other

What has been your aftercare treatment?

Out-Patient Counseling Self-Help Meetings

I need referrals for further treatment

If you still require referrals please describe what type:

What was your overall impression of the treatment experience at North Cottage?

Do you have any additional comments?

Treatment

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