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Crossroads Behavioral Health Services
1003 Cottonwood Rd
Phone 641-782-8457
Fax 641-782-7048
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Gender:  *  
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
* 1. What program did you receive services in?
Mental Health Outpatient ONLY   Substance Use Outpatient and Mental Health Outpatient   Substance Use Outpatient ONLY  
* 2. This is a confidential and private place.
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 felt comfortable sharing treatment concerns with my care provider.
strongly agree   agree   disagree  
strongly disagree     
* 5. Treatment/counseling was focused on achieving my goals and fit my needs.
strongly agree   agree   disagree  
strongly disagree     
* 6. The care provider explained things in a way I understood.
strongly agree   agree   disagree  
strongly disagree     
* 7. I was treated with respect by all staff.
strongly agree   agree   disagree  
strongly disagree     
* 8. The office staff answered my questions and helped if there was a problem.
strongly agree   agree   disagree  
strongly disagree     
* 9. Did you and your care provider develop a discharge/continuing care plan (what you will do after you leave)?
Yes   No   N/A  
* 10. Did staff connect you with primary health care services (medical doctor)?
Yes   No   N/A  
* 11. Were you given referrals for additional services, if needed?
Yes   No   N/A  
* 12. Would you recommend our agency to friends and family?
Yes   No    
* 13. Who sent you here for services?
Parole/Probation  
Court system  
Attorney  
DHS  
School  
EAP/Employer  
Friend/Family Member  
Self  
Other  
14. Who is your care provider at Crossroads?
15. Comments and feedback
* 17. What is your age?
Under 12   13-17   18-30  
31-64   65+    
* 16. What is your gender identification?
male   female   transgender  
prefer not to say   other    
* 18. Which race/ethnicity best describes you?
American Indian or Alaskan Native   Asian / Pacific Islander   Black or African American  
Hispanic   White / Caucasian   Multiple ethnicity / Other (please specify)  
What office location were you seen in?
Winterset   Creston   Osceola  
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