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* 1. Date Survey Completed

Date

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* 2. Site:

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

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

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

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

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

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

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

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

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

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

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* 13. Comments

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* 14. For Office Use:  Contact Method?

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* 15. For Office Use:  Contact Results:

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* 16. For Office Use:  Follow-up:

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