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Survey - Client Satisfaction - New Client

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?
Parole/Probation  
Court system  
Attorney  
DHS  
School  
EAP/Employer  
Friend or Family Member  
Self  
Other  
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  
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