* 1. Our records show that you receive care from a therapist or prescriber.. Is that right?

* 2. From which CHD clinic(s) do you receive services

* 3. Do you see a therapist, a prescriber (for medication), or both?

* 4. How long have you been going to this CHD clinic?

* 5. In the last 12 months, how many times did you visit a CHD clinic?

* 6. In the last 12 months, when you phoned CHD’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?

* 7. In the last 12 months, did you make any appointments for a check-up or routine care with therapist or prescriber?

* 8. In the last 12 months, when you made an appointment for a check-up or routine care with therapist or prescriber, how often did you get an appointment as soon as you needed?

* 9. In the last 12 months, did you phone your therapist or prescriber’s office with a question after regular office hours?

* 10. In the last 12 months, when you phoned therapist or prescriber’s office after regular office hours, how often did you get an answer to your question as soon as you needed?

* 11. Wait time includes time spent in the waiting room. During your most recent visit, did you see your healthcare provider within 15 minutes of your appointment time?

* 12. During your most recent visit, did your therapist or prescriber explain things in a way that was easy to understand?

* 13. During your most recent visit, did your therapist or prescriber listen carefully to you?

* 14. During your most recent visit, did your therapist or prescriber give you easy to understand information about your questions or concerns?

* 15. During your most recent visit, did your therapist or prescriber seem to know the important information about your mental health history?

* 16. During your most recent visit, did your therapist or prescriber show respect for what you had to say?

* 17. During your most recent visit, did your therapist or presecriber spend enough time with you?

* 18. Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate therapist or prescriber?

  10 Best provider possible 9 8 7 6 5 4 3 2 1 0 Worst provider possible
.

* 19. Would you recommend this CHD clinic to your family and friends?

* 20. During your most recent visit, were clerks and receptionists at this office as helpful as you thought they should be?

* 21. During your most recent visit, did clerks and receptionists at this office treat you with courtesy and respect?

* 22. In general, how would you rate your overall health?

* 23. In general, how would you rate your overall mental or emotional health?

* 24. What is your age?

* 25. Are you male or female?

* 26. What is the highest grade or level of school that you have completed?

* 27. Are you of Hispanic or Latino origin or descent?

* 28. What is your race? Mark one or more.

* 29. Did someone help you complete this survey?

* 30. How did that person help you? Mark one or more.

T