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Survey - Client Satisfaction - Discharge
Crossroads Behavioral Health Services
210 Russell Street
Phone 641-782-8457
Fax 641-782-7048
Client Information
First Name:
*
Last Name:
*
Date of Birth:
*
Birth Sex:
*
Address:
City:
State:
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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?
TBD
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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