Westbrook Referrer Survey

This survey is provided to help Westbrook Health Services gauge the referrer's impression of our services. Your answers are confidential and are only used to evaluate and improve the programs we offer. We appreciate your taking the time to respond candidly to our questions and in helping us to improve our services to the community.

Question Title

1. What is your opinion of this statement?

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
Westbrook's services are equal to that of any behavioral health provider in our region.	Westbrook's services are equal to that of any behavioral health provider in our region. Strongly Agree	Westbrook's services are equal to that of any behavioral health provider in our region. Agree	Westbrook's services are equal to that of any behavioral health provider in our region. Neutral	Westbrook's services are equal to that of any behavioral health provider in our region. Disagree	Westbrook's services are equal to that of any behavioral health provider in our region. Strongly Disagree

Comment or elaboration

Question Title

2. How would you rate your satisfaction with Westbrook's different service options?

	Very Satisfied	Satisfied	Neutral	Dissatisfied	NA/Unsure
a) Detox and Residential Substance Abuse (Amity)	a) Detox and Residential Substance Abuse (Amity) Very Satisfied	a) Detox and Residential Substance Abuse (Amity) Satisfied	a) Detox and Residential Substance Abuse (Amity) Neutral	a) Detox and Residential Substance Abuse (Amity) Dissatisfied	a) Detox and Residential Substance Abuse (Amity) NA/Unsure
b) Outpatient Substance Abuse	b) Outpatient Substance Abuse Very Satisfied	b) Outpatient Substance Abuse Satisfied	b) Outpatient Substance Abuse Neutral	b) Outpatient Substance Abuse Dissatisfied	b) Outpatient Substance Abuse NA/Unsure
c) Developmental Disabilities (MRDD)	c) Developmental Disabilities (MRDD) Very Satisfied	c) Developmental Disabilities (MRDD) Satisfied	c) Developmental Disabilities (MRDD) Neutral	c) Developmental Disabilities (MRDD) Dissatisfied	c) Developmental Disabilities (MRDD) NA/Unsure
d) Children and Family Services	d) Children and Family Services Very Satisfied	d) Children and Family Services Satisfied	d) Children and Family Services Neutral	d) Children and Family Services Dissatisfied	d) Children and Family Services NA/Unsure
e) Physician Services	e) Physician Services Very Satisfied	e) Physician Services Satisfied	e) Physician Services Neutral	e) Physician Services Dissatisfied	e) Physician Services NA/Unsure
f) Adult Mental Health Services	f) Adult Mental Health Services Very Satisfied	f) Adult Mental Health Services Satisfied	f) Adult Mental Health Services Neutral	f) Adult Mental Health Services Dissatisfied	f) Adult Mental Health Services NA/Unsure
g) Crisis Care Coordination	g) Crisis Care Coordination Very Satisfied	g) Crisis Care Coordination Satisfied	g) Crisis Care Coordination Neutral	g) Crisis Care Coordination Dissatisfied	g) Crisis Care Coordination NA/Unsure
h) Adult Crisis Stabilization	h) Adult Crisis Stabilization Very Satisfied	h) Adult Crisis Stabilization Satisfied	h) Adult Crisis Stabilization Neutral	h) Adult Crisis Stabilization Dissatisfied	h) Adult Crisis Stabilization NA/Unsure
i) Psychological Testing and Evaluation	i) Psychological Testing and Evaluation Very Satisfied	i) Psychological Testing and Evaluation Satisfied	i) Psychological Testing and Evaluation Neutral	i) Psychological Testing and Evaluation Dissatisfied	i) Psychological Testing and Evaluation NA/Unsure

Comments or elaboration

Question Title

3. Of the following characteristics, how much emphasis do you place on each one when deciding where to refer a client?

	None	A Little	Some	A Great Deal
a) Agency personnel	a) Agency personnel None	a) Agency personnel A Little	a) Agency personnel Some	a) Agency personnel A Great Deal
b) Available programs	b) Available programs None	b) Available programs A Little	b) Available programs Some	b) Available programs A Great Deal
c) Expertise with specific diagnoses	c) Expertise with specific diagnoses None	c) Expertise with specific diagnoses A Little	c) Expertise with specific diagnoses Some	c) Expertise with specific diagnoses A Great Deal
d) Client preferences	d) Client preferences None	d) Client preferences A Little	d) Client preferences Some	d) Client preferences A Great Deal
e) Client insurance	e) Client insurance None	e) Client insurance A Little	e) Client insurance Some	e) Client insurance A Great Deal
f) Agency Reputation	f) Agency Reputation None	f) Agency Reputation A Little	f) Agency Reputation Some	f) Agency Reputation A Great Deal
g) Speed in seeing client	g) Speed in seeing client None	g) Speed in seeing client A Little	g) Speed in seeing client Some	g) Speed in seeing client A Great Deal

Comments or elaboration

Question Title

4. How would you rate Westbrook Health Services in terms of the following dimensions?

	Poor	Fair	Good	Very Good	Excellent
a) Convenience of Locations	a) Convenience of Locations Poor	a) Convenience of Locations Fair	a) Convenience of Locations Good	a) Convenience of Locations Very Good	a) Convenience of Locations Excellent
b) Responsiveness of Staff	b) Responsiveness of Staff Poor	b) Responsiveness of Staff Fair	b) Responsiveness of Staff Good	b) Responsiveness of Staff Very Good	b) Responsiveness of Staff Excellent
c) Hours of Operation	c) Hours of Operation Poor	c) Hours of Operation Fair	c) Hours of Operation Good	c) Hours of Operation Very Good	c) Hours of Operation Excellent
d) Facility Cleanliness and Comfort	d) Facility Cleanliness and Comfort Poor	d) Facility Cleanliness and Comfort Fair	d) Facility Cleanliness and Comfort Good	d) Facility Cleanliness and Comfort Very Good	d) Facility Cleanliness and Comfort Excellent
e) Range of Services	e) Range of Services Poor	e) Range of Services Fair	e) Range of Services Good	e) Range of Services Very Good	e) Range of Services Excellent
f) Parking and Accessibility	f) Parking and Accessibility Poor	f) Parking and Accessibility Fair	f) Parking and Accessibility Good	f) Parking and Accessibility Very Good	f) Parking and Accessibility Excellent
g) Professionalism of Staff	g) Professionalism of Staff Poor	g) Professionalism of Staff Fair	g) Professionalism of Staff Good	g) Professionalism of Staff Very Good	g) Professionalism of Staff Excellent

Comments or elaboration

Question Title

5. How would you characterize your satisfaction with Westbrook's services?

	Very Satisfied	Satisfied	Undecided	Dissatisfied	Very Dissatisfied
a) Westbrook's care of your client	a) Westbrook's care of your client Very Satisfied	a) Westbrook's care of your client Satisfied	a) Westbrook's care of your client Undecided	a) Westbrook's care of your client Dissatisfied	a) Westbrook's care of your client Very Dissatisfied
b) Benefits client received from treatment	b) Benefits client received from treatment Very Satisfied	b) Benefits client received from treatment Satisfied	b) Benefits client received from treatment Undecided	b) Benefits client received from treatment Dissatisfied	b) Benefits client received from treatment Very Dissatisfied
c) Communication regarding treatment process	c) Communication regarding treatment process Very Satisfied	c) Communication regarding treatment process Satisfied	c) Communication regarding treatment process Undecided	c) Communication regarding treatment process Dissatisfied	c) Communication regarding treatment process Very Dissatisfied
d) Communication regarding treatment plan	d) Communication regarding treatment plan Very Satisfied	d) Communication regarding treatment plan Satisfied	d) Communication regarding treatment plan Undecided	d) Communication regarding treatment plan Dissatisfied	d) Communication regarding treatment plan Very Dissatisfied
e) Access to admission/referral process	e) Access to admission/referral process Very Satisfied	e) Access to admission/referral process Satisfied	e) Access to admission/referral process Undecided	e) Access to admission/referral process Dissatisfied	e) Access to admission/referral process Very Dissatisfied
f) Efficiency of referral process	f) Efficiency of referral process Very Satisfied	f) Efficiency of referral process Satisfied	f) Efficiency of referral process Undecided	f) Efficiency of referral process Dissatisfied	f) Efficiency of referral process Very Dissatisfied
g) Communication regarding discharge planning	g) Communication regarding discharge planning Very Satisfied	g) Communication regarding discharge planning Satisfied	g) Communication regarding discharge planning Undecided	g) Communication regarding discharge planning Dissatisfied	g) Communication regarding discharge planning Very Dissatisfied

Comments or elaboration

Question Title

6. Would you refer another consumer to Westbrook Health Services?

Yes

Question Title

7. Which clinical services do you feel are most in need in our community?

	Critical Need	Significant Need	Moderate Need	Minimal Need	No Need
a) Psychiatrist Availability	a) Psychiatrist Availability Critical Need	a) Psychiatrist Availability Significant Need	a) Psychiatrist Availability Moderate Need	a) Psychiatrist Availability Minimal Need	a) Psychiatrist Availability No Need
b) Psychological Testing and Evaluation	b) Psychological Testing and Evaluation Critical Need	b) Psychological Testing and Evaluation Significant Need	b) Psychological Testing and Evaluation Moderate Need	b) Psychological Testing and Evaluation Minimal Need	b) Psychological Testing and Evaluation No Need
c) Specialized Children Assessment and Treatment (e.g., Autism, Asperger's)	c) Specialized Children Assessment and Treatment (e.g., Autism, Asperger's) Critical Need	c) Specialized Children Assessment and Treatment (e.g., Autism, Asperger's) Significant Need	c) Specialized Children Assessment and Treatment (e.g., Autism, Asperger's) Moderate Need	c) Specialized Children Assessment and Treatment (e.g., Autism, Asperger's) Minimal Need	c) Specialized Children Assessment and Treatment (e.g., Autism, Asperger's) No Need
d) Inservices or Workshops on Behavioral Health Issues	d) Inservices or Workshops on Behavioral Health Issues Critical Need	d) Inservices or Workshops on Behavioral Health Issues Significant Need	d) Inservices or Workshops on Behavioral Health Issues Moderate Need	d) Inservices or Workshops on Behavioral Health Issues Minimal Need	d) Inservices or Workshops on Behavioral Health Issues No Need
e) Crisis or Intensive Services for Children/Adolescents	e) Crisis or Intensive Services for Children/Adolescents Critical Need	e) Crisis or Intensive Services for Children/Adolescents Significant Need	e) Crisis or Intensive Services for Children/Adolescents Moderate Need	e) Crisis or Intensive Services for Children/Adolescents Minimal Need	e) Crisis or Intensive Services for Children/Adolescents No Need
f) Substance Abuse Services	f) Substance Abuse Services Critical Need	f) Substance Abuse Services Significant Need	f) Substance Abuse Services Moderate Need	f) Substance Abuse Services Minimal Need	f) Substance Abuse Services No Need
g) Treatment for Eating Disorders	g) Treatment for Eating Disorders Critical Need	g) Treatment for Eating Disorders Significant Need	g) Treatment for Eating Disorders Moderate Need	g) Treatment for Eating Disorders Minimal Need	g) Treatment for Eating Disorders No Need

Other (please specify)

Question Title

8. What other resources do you use to meet the behavioral health needs of your consumers? (please select all that apply)

a) Independent Mental Health Providers

b) Other Community Mental Health Centers

c) Regional Hospital Emergency Departments

d) Regional Hospital Behavioral Health Centers

e) Department of Health and Human Resources

f) Judicial System

g) Law Enforcement

Other (please specify)

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9. Are there any recommendations or suggestions you might offer Westbrook to assist in our efforts to provide quality healthcare to our community?

Question Title

10. We would appreciate your sharing contact information with our agency so we may reach you to discuss any concerns you may have.

Name:

Company:

Address:

Address 2:

City/Town:

State:

ZIP/Postal Code:

Email Address:

Phone Number: