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

* 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.

* 4. Which category below includes your age?

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

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

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

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

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

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

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

* 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.

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

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

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

* 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)

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

Report a problem