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* 1. Name (optional)

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* 2. Clinician/Intern/Nurse

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* 3. I am treated with courtesy and respect; and our privacy and confidentiality are protected by the Outpatient staff.

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* 4. I feel as though I was offered my first appointment (Clinical Intake or Psychiatric Evaluation), in a timely manner.

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* 5. My telephone calls/messages are returned in a timely manner.

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* 6. At my first appointment (Clinical Intake or Psychiatric Evaluation), all CCS forms were reviewed with me and my questions were answered

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* 7. I feel that I am actively involved in the development of my/my child treatment goals (Individualized Service Plan).

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* 8. I feel that my provider(clinician/nurse) listens to my concerns; takes my opinion into consideration

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* 9. Overall, I am satisfied with the services I received with Cooperative Counseling Services.

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* 10. If there is anything else you would like to add, please comment in the space provided below

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