New Patient Survey We appreciate you taking the time to complete this survey. The survey will take about 5 minutes to complete, is confidential and will be utilized to improve the performance at UCS Healthcare. OK Question Title * 1. What location are you at today? Ankeny Des Moines Knoxville OK Question Title * 2. This is a confidential and private place. strongly agree agree disagree strongly disagree OK Question Title * 3. I am satisfied with the amount of time it took to access services. strongly agree agree disagree strongly disagree OK Question Title * 4. The care provider was helpful and listened to my concerns. strongly agree agree disagree strongly disagree OK Question Title * 5. I was treated with respect by all staff. strongly agree agree disagree strongly disagree OK Question Title * 6. Who sent you here for services Parole/Probation Court System DHS Attorney School EAP/Employer Friend/Family Member Self OK Question Title * 7. I was able to schedule appointments with my counselor/therapist that work with my schedule. strongly agree agree disagree strongly Disagree OK Question Title * 8. How much time did it take to fill out initial forms before seeing my provider? Less than 15 minutes 15-29 minutes 30-44 minutes 45-59 minutes 60+ minutes OK Question Title * 9. What type of an assessment did you come in for? Medication Assisted Treatment Mental Health Substance Use Disorder OK Question Title * 10. After your initial paperwork was complete, how long did you wait in the waiting room for your appointment? Less than 5 minutes Less than 10 minutes 10-30 minutes 30-60 minutes More than 60 minutes OK Question Title * 11. The waiting room was comfortable and neat (lighting, furniture, cleanliness). strongly agree agree disagree strongly disagree OK Question Title * 12. Insurance and billing were clearly explained to me at intake. Strongly agree Agree Disagree Strongly disagree OK Question Title * 13. What type of appointment do you prefer? Walk In Scheduled OK Question Title * 14. I feel safe when in or around the building. strongly agree agree disagree strongly disagree OK Question Title * 15. Optional: Name of care provider OK Question Title * 16. Optional: Comments and feedback OK Question Title * 17. What is your gender identification? male female transgender prefer not to say Other OK Question Title * 18. What is your age? Under 12 13-17 18-30 31-64 65+ OK Question Title * 19. Which race/ethnicity best describes you? American Indian or Alaskan Native Hispanic Latino Asian/Pacific Islander White / Caucasian Black or African American Multiple ethnicity / Other (please specify) OK DONE