Home
About
Appointments & Forms
New Client Intake Form
Returning Client Form
Release of Information Form
Health Screeners
Services & Staff
Employment
PNP
Case Managers
Bilingual Case Mgrs
Reception
Clinical Therapist
Contact Us
Staff Resources
CBHC Forms
Resources
Staff Meeting Updates
CLIENT SURVEY
NEW HIRE FORMS
Home
About
Appointments & Forms
New Client Intake Form
Returning Client Form
Release of Information Form
Health Screeners
Services & Staff
Employment
PNP
Case Managers
Bilingual Case Mgrs
Reception
Clinical Therapist
Contact Us
Staff Resources
CBHC Forms
Resources
Staff Meeting Updates
CLIENT SURVEY
NEW HIRE FORMS
Your experience with CBHC is important to us. Your answers
will be kept anonymous and confidential and will only be used for internal
use to help us improve our services. Thank you!
General
Does our staff call you by name?
*
Yes
Sometimes
No
Doesn't Apply
Do you feel that your personal dignity is maintained?
*
Yes
Sometimes
No
Doesn't Apply
Do you receive satisfactory answers to your questions?
*
Yes
Sometimes
No
Doesn't Apply
Are you satisfied with the thoroughness of care you receive?
*
Yes
Sometimes
No
Doesn't Apply
Do you feel confident you are receiving treatments and medications intended for you?
*
Yes
Sometimes
No
Doesn't Apply
Do you feel there is adequate communication among our psychiatrists, counselors and CPST staff regarding your treatment?
*
Yes
Sometimes
No
Doesn't Apply
Do our psychiatrists keep you informed about your condition and your care plan?
*
Yes
Sometimes
No
Doesn't Apply
9. Are you adequately involved with decisions affecting your care?
*
Yes
Sometimes
No
Doesn't Apply
Improvment
Has the condition for which you are being treated improved?
*
Yes
Somewhat
No
Doesn't Apply
Are you satisfied with how well your condition has improved?
*
Yes
Somewhat
No
Doesn't Apply
Are you satisfied with the thoroughness of care you receive from our staff?
*
Yes
Somewhat
No
Doesn't Apply
Does our staff adequately explain your treatment to you?
*
Yes
Somewhat
No
Doesn't Apply
Would you recommend us to your friends or family?
*
Yes
Somewhat
No
Doesn't Apply
Overall, are you satisfied with your treatment?
*
Yes
Somewhat
No
Doesn't Apply
Safety
Do you feel safe in CBHC’s office?
*
Yes
Somewhat
No
Doesn't Apply
Do you feel safe in the presence of Physicians/Psychiatrists?
*
Yes
Somewhat
No
Doesn't Apply
Do you feel safe in the presence of Social Workers/Counselors?
*
Yes
Somewhat
No
Doesn't Apply
Do you feel safe in the presence of your Case Manager?
*
Yes
Somewhat
No
Doesn't Apply
Courtesy
How would you rate the courtesy of the following staff?
Psychiatrists/Nursing Care
*
No Answer
Very Good
Good
Fair
Poor
Very Poor
Doesn't Apply
Social Workers/Counselors
*
No Answer
Very Good
Good
Fair
Poor
Very Poor
Doesn't Apply
CPST/Case Manager
*
No Answer
Very Good
Good
Fair
Poor
Very Poor
Doesn't Apply
Receptionist/ Office Staff
*
No Answer
Very Good
Good
Fair
Poor
Very Poor
Doesn't Apply
Overall ratings
What is your overall opinion of:
Your Psychiatrist
*
No Answer
Very Good
Good
Fair
Poor
Very Poor
Doesn't Apply
Social Worker/Councelor
*
No Answer
Very Good
Good
Fair
Poor
Very Poor
Doesn't Apply
CPST/Case Manager
*
No Answer
Very Good
Good
Fair
Poor
Very Poor
Does't Apply
The overall quality of care received
*
No Answer
Very Good
Good
Fair
Poor
Very Poor
Doesn't Apply
Please tell us:
What do you like most about CBHC?
*
How can we improve our service?
*
How can we make our organization safer for our clients?
*
How likely are you to recommend CBHC to a friend or family member?
*
Do you have any additional comments or feelings you would like to express about CBHC?
*
Optional:
If you would like to be contacted by a representative to discuss any aspect of your treatment, please include your name and a daytime phone number.
Name
*
Phone Number
*
Thank you for taking the time to help us learn how we can improve our services!
Submit
