1.Did you receive a bill after a 5150 or involuntary committment?

Yes

No

2.If ys to questions 1, mark all that apply

Were you billed by the Hospital?

Were you billed by the Ambulance Service?

Were you billed by your insurance?

Other (please specify)

3.What county did you live in at the time of your hospitalization?

4.Were you forced to take medication against your will?

Yes

No

5.If yes to question 4, please select one below

When I left the hospital I continued to take the medication

When I left the hospital I stopped taking the medication

Other (please specify)

6.While in the hospital did you experience restraints?

We define restraints as any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces an individual's ability to move their arms, legs, body, or head freely

Yes

No

7.Were you placed in seclusion while you were in the hospital?

We define seclusion as: involuntary confinement of a person alone in a room or area from which they are physically prevented from leaving.

Yes

No

8.Please describe your overall hospital experience

9.Are you willing to discuss these experiences with us? If so, please give us your first name and phone number.