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**On a scale of 1 to 5, with 5 being the easiest / best, please rate us!**

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* 1. What department were you specifically visiting and giving feedback on today?

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* 2. How easy was it to schedule an appointment with this department?

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* 3. How long did you wait, beyond your appointment time, to be seen by the service provider?

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* 4. How would you rate the overall care you received today from this provider (doctor, dentist, pharmacist, mental health therapist, transporter, etc.)?

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* 5. How would you rate the overall care you received from check-in until you left this department?

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* 6. Were your questions answered in an easy to understand manner by this department?

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* 7. Did you leave this department today with an understanding of any follow up (appointments, referrals, etc.) that need to happen?

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* 8. After contacting Yellowhawk for this need, how quick did you receive an appointment or service?

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* 9. When was the last time you visited this department?

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* 10. During this visit, did you feel you experienced any form of discrimination or did you feel staff expressed personal bias?

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* 11. What barriers do you experience in keeping your appointments?

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* 12. How likely are you to recommend Yellowhawk to a friend or family member?

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* 13. What do you like the most about Yellowhawk and your visit today? (Please be specific and check all that apply)

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* 14. What do you like the least about Yellowhawk and your visit today? Any suggestions on how we can improve? (Please be specific and check all that apply)

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