Primary Health Choice, Inc. Client Follow-Up Survey

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* 1. Discharge Date

Date / Time

Date

As part of Primary Health Choice's ongoing commitment to quality service, please provide feedback regarding your current status since leaving our program. Please complete this survey at your earliest possible convenience. Thank you for allowing us to serve you.

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* 2. Service Location

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* 3. Service

Community Support Team

Day Treatment

IIH

MH/SA TCM

NC Innovations Waiver

PSR

Psychiatric Services

TCM I/DD

Therapy

Other (please specify)

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* 4. Have you been hospitalized or incarcerated since leaving the program at Primary Health Choice, ? If yes, then why and when?

Yes

If yes, please provide the reason.

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* 5. Have you been compliant with your medications since leaving the program at Primary Health Choice? Yes or No, If No, why?

Yes

If No, Why?

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* 6. Have you made progress since leaving the program at Primary Health Choice? Yes or No. If No, why?

Yes

If No, Why?

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* 7. Have you felt the need to return to the program or had a elapse since leaving the program at Primary Health Choice?

Yes

If Yes, why?

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* 8. Would you tell someone else about the services offered by Primary Health Choice? Yes or No. If No, why?

Yes