We hope you are doing well and would love to hear from you to know how things are going. As part of our ongoing commitment to quality service, we would like to obtain some feedback regarding your current status since leaving our program. Please answer the following questions and provide additional comments as needed. Thank you!

Question Title

* 1. Date Survey Completed

Date

Question Title

* 2. Site/Location:

Question Title

* 3. What programs/services are you involved in at Mark Twain Behavioral Health: (Select all that apply)

Question Title

* 4. Since leaving services at Mark Twain Behavioral Health, have you been hospitalized for substance use or mental health treatment or used crisis services?

Question Title

* 5. Since leaving services at Mark Twain Behavioral Health, have you encountered any legal issues or incarceration?

Question Title

* 6. Since leaving services at Mark Twain Behavioral Health, have you experienced homelessness?

Question Title

* 7. To what degree did the services you received from Mark Twain Behavioral Health help you meet your goals and to be well?

Question Title

* 8. Since leaving services at Mark Twain Behavioral Health, have you remained compliant with your treatment goals?

Question Title

* 9. Since leaving services at Mark Twain Behavioral Health, do you feel that you have continued to make progress?

Question Title

* 10. Since leaving services at Mark Twain Behavioral Health, have you felt the need to return to the program or had a relapse?

Question Title

* 11. Were there any barriers/problems to your receiving services at Mark Twain Behavioral Health?

Question Title

* 12. Did we meet our goal of helping you to BE WELL?

Question Title

* 13. Any additional comments you would like to share:

Question Title

* 14. For Office Use:  Contact Method?

Question Title

* 15. For Office Use:  Contact Results:

Question Title

* 16. For Office Use:  Follow-up:

T