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Survey - Client Satisfaction - Mid-Treatment

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. 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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