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Alcohol & Drug Dependency Services
1340 Mt. Pleasant Street
Phone 319-753-6567
Fax 319-753-0703
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Gender:  *  
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
* Who is your counselor at ADDS?
* 1. This is a confidential and private place.
Strongly agree   agree   disagree  
strongly disagree     
* 2. I am satisfied with the amount of time it took to access services.
strongly agree   agree   disagree  
strongly disagree     
* 3. The care provider was helpful and listened to my concerns.
strongly agree   agree   disagree  
strongly disagree     
* 4. I was treated with respect by all staff.
strongly agree   agree   disagree  
strongly disagree     
* 5. Who sent you here for services?
Parole/Probation   Court System   Attorney  
DHS   School   EAP/Employer  
Friend/Family Member   Self    
* 7. Comments and feedback
* 8. What is your age?
Under 12   13-17   18-30  
31-64   65+    
* 9. What is your gender identification?
male   female   transgender  
prefer not to say   Other    
* 10. Which race/ethnicity best describes you?
American Indian or Alaskan Native   Asian/Pacific Islander   Hispanic  
Latino   Black or African American   White/Caucasian  
Multiple Ethnicity/Other (please specify)     
* 11. What potential barriers do you think you will experience as you reintegrate into your community after treatment? Please answer if this is applicable to you.
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