Submit
Cancel
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 are you receiving services in?
Mental Health Outpatient ONLY  
Substance Use Outpatient ONLY  
Substance Use and Mental Health Outpatient  
* 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
* 14. What is your age?
Under 12  
13-17  
18-30  
31-64  
65+  
* 13. 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?
Winterset   Creston   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.