Referral Source Survey ABH, Inc

Thank you!

Advanced Behavioral Health appreciates the trust that you have given us by referring your patients/clients or consumers to us for mental health treatment. It is our commitment to better serve you and the community, therefore we appreciate your feedback. Please take a moment to complete this survey.

Question Title

* Please check the ABH office(s) that you made your referral(s) to:

Baltimore

Carroll

Frederick

Greenbelt

Montgomery Co.

Community Schools/TNI

Question Title

* REFERRALS

	Strongly Agree	Agree	Disagree	Strongly Disagree	N/A
1. When I have referred someone to this organizaiton, I believe that they were given an appointment within a reasonable time.	1. When I have referred someone to this organizaiton, I believe that they were given an appointment within a reasonable time. Strongly Agree	1. When I have referred someone to this organizaiton, I believe that they were given an appointment within a reasonable time. Agree	1. When I have referred someone to this organizaiton, I believe that they were given an appointment within a reasonable time. Disagree	1. When I have referred someone to this organizaiton, I believe that they were given an appointment within a reasonable time. Strongly Disagree	1. When I have referred someone to this organizaiton, I believe that they were given an appointment within a reasonable time. N/A

Question Title

* COMMUNICATION

	Strongly Agree	Agree	Disagree	Strongly Disagree	N/A
2. When I last telephoned, the call was answered in a courteous manner.	2. When I last telephoned, the call was answered in a courteous manner. Strongly Agree	2. When I last telephoned, the call was answered in a courteous manner. Agree	2. When I last telephoned, the call was answered in a courteous manner. Disagree	2. When I last telephoned, the call was answered in a courteous manner. Strongly Disagree	2. When I last telephoned, the call was answered in a courteous manner. N/A
3. My calls to staff are returned promptly.	3. My calls to staff are returned promptly. Strongly Agree	3. My calls to staff are returned promptly. Agree	3. My calls to staff are returned promptly. Disagree	3. My calls to staff are returned promptly. Strongly Disagree	3. My calls to staff are returned promptly. N/A
4. Staff is responsive to my inquiries or concerns.	4. Staff is responsive to my inquiries or concerns. Strongly Agree	4. Staff is responsive to my inquiries or concerns. Agree	4. Staff is responsive to my inquiries or concerns. Disagree	4. Staff is responsive to my inquiries or concerns. Strongly Disagree	4. Staff is responsive to my inquiries or concerns. N/A
5. Staff provides timely feedback regarding disposition of referrals or service contacts.	5. Staff provides timely feedback regarding disposition of referrals or service contacts. Strongly Agree	5. Staff provides timely feedback regarding disposition of referrals or service contacts. Agree	5. Staff provides timely feedback regarding disposition of referrals or service contacts. Disagree	5. Staff provides timely feedback regarding disposition of referrals or service contacts. Strongly Disagree	5. Staff provides timely feedback regarding disposition of referrals or service contacts. N/A
6. If an appropriate Release of Information was signed by the client, I receive a report regarding assessment and treatment recommendations.	6. If an appropriate Release of Information was signed by the client, I receive a report regarding assessment and treatment recommendations. Strongly Agree	6. If an appropriate Release of Information was signed by the client, I receive a report regarding assessment and treatment recommendations. Agree	6. If an appropriate Release of Information was signed by the client, I receive a report regarding assessment and treatment recommendations. Disagree	6. If an appropriate Release of Information was signed by the client, I receive a report regarding assessment and treatment recommendations. Strongly Disagree	6. If an appropriate Release of Information was signed by the client, I receive a report regarding assessment and treatment recommendations. N/A
7. After-hours calls are answered promptly.	7. After-hours calls are answered promptly. Strongly Agree	7. After-hours calls are answered promptly. Agree	7. After-hours calls are answered promptly. Disagree	7. After-hours calls are answered promptly. Strongly Disagree	7. After-hours calls are answered promptly. N/A

Question Title

* SERVICES

	Strongly Agree	Agree	Disagree	Strongly Disagree	N/A
8. Services received from the staff of this organization meet the needs of individuals being served.	8. Services received from the staff of this organization meet the needs of individuals being served. Strongly Agree	8. Services received from the staff of this organization meet the needs of individuals being served. Agree	8. Services received from the staff of this organization meet the needs of individuals being served. Disagree	8. Services received from the staff of this organization meet the needs of individuals being served. Strongly Disagree	8. Services received from the staff of this organization meet the needs of individuals being served. N/A
9. Staff help individuals that I have referred obtain the right kind of service for their problem(s).	9. Staff help individuals that I have referred obtain the right kind of service for their problem(s). Strongly Agree	9. Staff help individuals that I have referred obtain the right kind of service for their problem(s). Agree	9. Staff help individuals that I have referred obtain the right kind of service for their problem(s). Disagree	9. Staff help individuals that I have referred obtain the right kind of service for their problem(s). Strongly Disagree	9. Staff help individuals that I have referred obtain the right kind of service for their problem(s). N/A
10. Staff have been courteous, knowledgeable, and helpful.	10. Staff have been courteous, knowledgeable, and helpful. Strongly Agree	10. Staff have been courteous, knowledgeable, and helpful. Agree	10. Staff have been courteous, knowledgeable, and helpful. Disagree	10. Staff have been courteous, knowledgeable, and helpful. Strongly Disagree	10. Staff have been courteous, knowledgeable, and helpful. N/A

Question Title

* OVERALL SATISFACTION

	Strongly Agree	Agree	Disagree	Strongly Disagree	N/A
11. In general, I have been satisfied with the services provided by this organization.	11. In general, I have been satisfied with the services provided by this organization. Strongly Agree	11. In general, I have been satisfied with the services provided by this organization. Agree	11. In general, I have been satisfied with the services provided by this organization. Disagree	11. In general, I have been satisfied with the services provided by this organization. Strongly Disagree	11. In general, I have been satisfied with the services provided by this organization. N/A

Question Title

* COMMENTS:

Question Title

* Name / Phone / email (OPTIONAL)

Name

Organization

Phone

Date