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Survey - Client Satisfaction - Mid-Treatment
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 are you receiving services in?
Mental Health Outpatient ONLY
Substance Use Outpatient ONLY
Substance Use and Mental Health Outpatient
Psychiatry
Mental Health and Psychiatry
Substance Use and Psychiatry
* 2. This is a confidential and private place.
strongly agree
agree
disagree
strongly disagree
* 3. The care provider is helpful and listens to my concerns.
strongly agree
agree
disagree
strongly disagree
* 4. I feel comfortable sharing treatment concerns with my care provider.
strongly agree
agree
disagree
strongly disagree
* 5. Treatment/counseling is focused on achieving my goals and fits my needs.
strongly agree
agree
disagree
strongly disagree
* 6. The care provider explains things in a way I understand.
strongly agree
agree
disagree
strongly disagree
* 7. I am treated with respect by all staff.
strongly agree
agree
disagree
strongly disagree
* 8. The office staff answer my questions and help if there is a problem.
strongly agree
agree
disagree
strongly disagree
* 9. Would you recommend our agency to friends and family?
Yes
No
* 10. Who sent you here for services?
Parole/Probation
Court system
Attorney
DHS
School
EAP/Employer
Friend/Family Member
Self
Other
Who is your Provider at Crossroads?
12. Comments and feedback
* 13. What is your age?
Under 12
13-17
18-30
31-64
65+
* 14. What is your gender identification
Male
Female
Transgender
Prefer not to say
Other
* 15. 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)
What office location were you seen in?
Creston
Winterset
Osceola
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