Errors
Thank You!
We appreciate the trust you have given us by referring patients to us for services. In our continued commitment to better serve you and your clients, we would appreciate your feedback. Please consider your overall interactions with our program when responding to the questions.
Your Name:
Your Organization:*
Program Code:*
Verification Code:*
1.
Ease of Admission Process
Excellent
Very Good
Good
Fair
Poor
N/A
2.
Timeliness of being Informed of the Disposition of your Referral
Excellent
Very Good
Good
Fair
Poor
N/A
3. Helpfulness of Staff
Excellent
Very Good
Good
Fair
Poor
N/A
4. Care Coordination Overall
Excellent
Very Good
Good
Fair
Poor
N/A
5. Quality of Patient Care
Excellent
Very Good
Good
Fair
Poor
N/A
6. Are We your Provider of Choice
Yes
No
Please provide us with any other information we should know.
What description best fits you or your organization (select best choice)*
Client Hospital
Mental Health Professional (non-Physician)
Social Service Organization
Community Hospital Medical Floor
General Healthcare Professional (non-Physician)
Law Enforcement/Judicial
Hospital Emergency Department
Psychiatrist
School/Educational
Crisis Center/CSU
Physician (non-psychiatrist)
Military/VA
Acute Care Psychiatric Facility
Assisted Living/Personal Care Facility
Insurance Company/Managed Care
Other Psychiatric Facility
Nursing Home
Clergy
Medical Hospital Staff (non-ED)
Community Mental Health Center
Other
