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* 1. Date

Date

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* 2. Site:

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* 3. What programs/services are you involved in at Mark Twain Behavioral Health: (Choose all that apply)

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* 4. Please rate the following questions.

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* 5. Accessibility, cleanliness and comfort of facilities

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* 6. Wait time until first appointment

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* 7. Helpfulness and friendliness of agency staff members

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* 8. The degree to which treatment helped you to deal with your problem/complaint

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* 9. The degree to which services have supported your efforts to become more self-sufficient

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* 10. Overall quality of care and services

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* 11. Please rate your agreement to the following statements.

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* 12. "I would recommend Mark Twain Behavioral Health to a friend."

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* 13. "I am satisfied with the services that I receive from Mark Twain Behavioral Health."

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* 14. Mark Twain Behavioral Health is a trusted leader that helps people be well.

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* 15. Do you feel safe in our facilities?

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* 16. Are there any problems/barriers to your receiving timely and effective services at Mark Twain Behavioral Health?

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* 17. How could Mark Twain Behavioral Health's services be improved?  Please share any comments.

Transportation Questions.  Please respond to the following questions if you have used MTBH transportation services.

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* 18. How satisfied were you with the transportation service?

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* 19. If you have used MTBH transportation services, do you feel like your transportation needs were met?

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* 20. If you have used MTBH transportation services, do you feel like you were treated fairly?

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* 21. Do you have any suggestions to improve our transportation services?  Please share comments.

Telehealth Questions.  Please respond to the following questions if you have used telehealth to see your provider (video conference - zoom or telephone).

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* 22. Telehealth Questions: (Video Conference (Zoom) or Telephone)

How satisfied were you with your personal comfort in using the telehealth system?

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* 23. Telehealth Questions: (Video Conference (Zoom) or Telephone)

How satisfied were you with your overall treatment experience using the telehealth system?

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* 24. Telehealth Questions:  Please rate your agreement to the statement:  "I would use telehealth again to see my provider."

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* 25. Comments

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