Demographic Questionnaire for Clients of The Anxiety and OCD Treatment Center of Ann Arbor Survey

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* 1. Are you a current or prospective client of The Anxiety and OCD Treatment Center of Ann Arbor

Current Client

Prospective Client

Neither

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* 2. In what state or U.S. territory do you live?

Other (please specify)

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* 3. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305) Enter 00000 if you're located in Canada.

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* 4. Which category below includes your age?

17 or younger

18-20

21-29

30-39

40-49

50-59

60 or older

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* 5. What is the highest level of school you have completed or the highest degree you have received?

Less than high school degree

High school degree or equivalent (e.g., GED)

Some college but no degree

Associate degree

Bachelor degree

Graduate degree

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* 6. How much total combined money did all members of your HOUSEHOLD earn last year?

$0 to $9,999

$10,000 to $24,999

$25,000 to $49,999

$50,000 to $74,999

$75,000 to $99,999

$100,000 to $124,999

$125,000 to $149,999

$150,000 to $174,999

$175,000 to $199,999

$200,000 and up

Prefer not to answer

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* 7. How many children age 17 or younger live in your household?

None

More than 4

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* 8. Does everyone in your household currently have health insurance, or not?

Yes, everyone does

No, everyone does not

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* 9. Where did you obtain your current health insurance plan?

Employer Sponsored - Self

Employer Sponsored- Spouse/Partner

Parents

Affordable Care Exchange

Disability

Government Sponsored (Medicare/Medicaid)

Other (please specify)

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* 10. Which company is your insurance coverage provided by?

Blue Care Network

Blue Cross Blue Shield

United Health Care

Aetna

Value Options/Beacon

Medicaid

Medicare

HAP

Priority Health

Other (please specify)

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* 11. Does your family use a flexible spending account (FSA) or health savings account (HSA) for healthcare costs?

Yes

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* 12. As you may know, our clinic offers skill-based classes on specific topics. These classes are approximately 4-6 weeks long and cost an average of $60 per class. If a skill-based class is offered on my specific diagnosis or concern, I would attend this class.

Yes

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* 13. What are barriers that would keep you from attending a skill based class?

Cost of the class

Scheduling Conflicts

Too anxiety provoking to participate

Confidentiality concerns

Don't see classes as effective

Other (please specify)

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* 14. Please rank in order of importance the barriers impeding your willingness to attend classes (1=greatest barrier and 5=hardly a barrier).

Cost of the class

N/A

Scheduling Conflicts

N/A

Too anxiety provoking to participate

N/A

Confidentiality concerns

N/A

Don't see classes as effective

N/A

Other reason listed above

N/A

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* 15. If a trainee was available for individual treatment, with no wait or minimal wait, would you be open to working with a trainee?

Yes

Other (please specify)

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* 16. Please rank in order of importance the barriers impeding your willingness to work with a trainee (1=greatest barrier and 4=hardly a barrier)

Cost Too High

N/A

Don't feel confident in treatment

N/A

Would not feel comfortable working with a therapist much younger than me

N/A

Other reason listed above

N/A

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* 17. What are reasons you WOULD be interested in treatment by a trainee? Select all that apply.

Cost is less than other clinicians

I can get into treatment much faster or without a wait

I like helping others receive training in my specialty area

Other (please specify)