Crossroads Behavioral Health Services
1003 Cottonwood Rd
Phone 641-782-8457
Fax 641-782-7048
 Client Information
  First Name:  * Last Name:  *  
  Date of Birth:  * Birth Sex: 
  Address: City:  
  State: Zip Code :  
  Phone No:  
* 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?
Court system  
Friend or Family Member  
6. Who is your care provider at Crossroads?
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 program are you receiving an evaluation for?
Mental Health   Substance Use   Psychiatry  
Mental Health and Substance Use     
* What office location were you seen in?
Creston   Winterset   Osceola  
Form Updates
Name Date Action
    Form Started
  1. Click the "Submit" button to save the data entered on this form.
  2. Click the "Cancel" button to exit without saving recent updates on this form.