*1.We're you able to complete your telehealth appointment today?(Required.)

Yes

No

2.We're you using a (check all that apply)

Device provided by CBHC

Personal device (includes device provided by CBHC Case Management of FIS Funding)

At CBHC Office

At home 

At other location

3.Issues experienced (check all that apply)

difficulty accessing telehealth waiting room or link for services

unable to hear

unable to maintain internet connection

unable to maintain video

call was moved to telephone

device was not compatible

couldn’t get to google chrome

didn’t know how to turn on device

no internet access

unable to see chat

4.Any additional information not included

5.Are we able to contact you if we need further information? (yes/no) and if yes... Contact information.