Online Family Survey

Treating patients relies on the support of family and friends. At Private Clinic Albany, we encourage and solicit your feedback in order to better serve our patients. Please take a moment to fill out the form below. We will not share or distribute personal information but rather use it internally.

Family Name	*required
Patient Name	*required
Relation to Patient	*required
How long has relative been in treatment at our Private Clinic Albany?	*required
Has your relative ever been in treatment before, if so type of treatment?	Yes No *required
Patient I.D.#	*required
E-Mail	*optional
Phone	*optional

Please take a few moments to answer these questions that will help us provide the best services possible to both our clients and their familes. We appreciate your time and comments.

1)	To your knowledge is the patient currently using:
	Opiate-based drugs?
	Other illicit drugs?
	Alcohol?

2)	Has the following behavior improved since entering treatment at Private Clinic Albany in the following areas?
	Trustworthiness?
	Responsibilty ?
	Reliability?

3)	Do the following relationships exbit more stability since patients has been in treatment at Private Clinic Albany.
	Patient and Family
	Patient and Spouse/significant other
	Patient and Children

4)	Has the patient has increased motivation in the following areas since entering treatment at Private Clinic Albany?
	Career/Job
	Meeting Family obligations
	Sports/Hobbies
	Attending social/spiritual functions

5)	To your knowledge has the patient been involved in illegal activity since beginning treatment at Private Clinic Albany?

6)	In your opinion has treatment at Private Clinic Albany had a positive impact on the patient's recovery in regards to opiate addiction?

7)	How often of you have contact with this family member?

8) Please add any additional comments you may have that were not specifically addressed in the survey above.