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Date
*
Month
/
Day
/
Year
PLEASE CHECK CSU:
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Please Select
CSU A
CSU B
ACCESS - I was able to talk with staff when I needed to.
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Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Not applicable
I received services when I needed them.
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Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Not applicable
I saw a psychiatrist within 24 hours of my admission.
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Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Not applicable
EFFECTIVENESS - I received services that were very helpful.
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Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Not applicable
The staff helped me find other services that I needed.
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Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Not applicable
I intend to follow through with outpatient recommendations after discharge.
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Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Not applicable
EFFICIENCY - If I had a complaint(s), it was handled well.
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Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Not applicable
My admission and discharge process was completed in a timely manner.
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Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Not applicable
OVERALL SATISFACTION - I was treated with respect.
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Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Not applicable
I am satisfied with the services I received.
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Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Not applicable
Additional Comments / How could we better serve you?
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