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Referral Survey (MentalHealthCare)
GomoWPAdmin
2019-05-14T15:58:16+00:00
Please complete the following information fields to the best of your ability.
During your contact with MentalHealthCares call line, were you given any referrals to behavioral health treatment services?
*
Yes
No
Were you able to get an appointment for the service(s) you were seeking?
*
Yes
No
How long did you wait to have your first appointment?
*
Within two weeks
More than one month
More than two months
Longer
How long did you wait for your first appointment?
*
If you have received services, have the services helped your situation?
*
Yes
No
Would you like further assistance from us?
*
Yes
No
Please provide the best number to reach you at:
*
How would you rate your overall satisfaction with MentalHealthCares services on a scale of 1-5?
*
5 - Excellent
4 - Good
3 - No Opinion
2 - Fair
1 - Poor
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