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* 1. What location are you receiving behavioral health care at?

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* 2. Our records show that you received care from a clinician in the last 12 months. Please type in the clinician's name below.

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* 3. People can get counseling, treatment or medicine for many different reasons, such as:
  • For feeling depressed, anxious, or “stressed out”
  • Personal problems (like when a loved one dies or when there are problems at work)
  • Family problems (like marriage problems or when parents and children have trouble getting along)
  • Needing help with drug or alcohol use
  • For mental or emotional illness

In the last 12 months, did you get counseling, treatment or medicine for any of these reasons?

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* 4. The next questions ask about your counseling or treatment. Do not include counseling or treatment during an overnight stay or from a self-help group.

In the last 12 months, did you call someone to get professional counseling on the phone for yourself?

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* 5. In the last 12 months, how often did you get the professional counseling you needed on the phone?

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* 6. In the last 12 months, did you need counseling or treatment right away?

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* 7. In the last 12 months, when you needed counseling or treatment right away, how often did you see someone as soon as you wanted?

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* 8. In the last 12 months, not counting times you needed counseling or treatment right away, did you make any appointments for counseling or treatment?

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* 9. In the last 12 months, not counting times you needed counseling or treatment right away, how often did you get an appointment for counseling or treatment as soon as you wanted?

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* 10. In the last 12 months, how many times did you go to an emergency room or crisis center to get counseling or treatment for yourself?

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* 11. In the last 12 months (not counting emergency rooms or crisis centers), how many times did you go to an office, clinic, or other treatment program to get counseling, treatment or medicine for yourself?

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* 12. In the last 12 months, how often were you seen within 15 minutes of your appointment?

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* 13. The next questions are about all the counseling or treatment you got in the last 12 months during office, clinic, and emergency room visits as well as over the phone. Please do the best you can to include all the different people you went to for counseling or treatment in your answers.

In the last 12 months, how often did the people you went to for counseling or treatment listen carefully to you?

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* 14. In the last 12 months, how often did the people you went to for counseling or treatment explain things in a way you could understand?

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* 15. In the last 12 months, how often did the people you went to for counseling or treatment show respect for what you had to say?

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* 16. In the last 12 months, how often did the people you went to for counseling or treatment spend enough time with you?

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* 17. In the last 12 months, how often did you feel safe when you were with the people you went to for counseling or treatment?

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* 18. In the last 12 months, did you take any prescription medicines as part of your treatment?

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* 19. In the last 12 months, were you told what side effects of those medicines to watch for?

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* 20. In the last 12 months, how often were you involved as much as you wanted in your counseling or treatment?

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* 21. In the last 12 months, did anyone talk to you about whether to include your family or friends in your counseling or treatment?

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* 22. In the last 12 months, were you told about self‑help or support groups, such as consumer‑run groups or 12‑step programs?

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* 23. In the last 12 months, were you given information about different kinds of counseling or treatment that are available?

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* 24. In the last 12 months, were you given as much information as you wanted about what you could do to manage your condition?

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* 25. In the last 12 months, were you given information about your rights as a patient?

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* 26. In the last 12 months, did you feel you could refuse a specific type of medicine or treatment?

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* 27. In the last 12 months, as far as you know did anyone you went to for counseling or treatment share information with others that should have been kept private?

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* 28. Does your language, race, religion, ethnic background or culture make any difference in the kind of counseling or treatment you need?

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* 29. In the last 12 months, was the care you received responsive to those needs?

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* 30. Using any number from 0 to 10, where 0 is the worst counseling or treatment possible and 10 is the best counseling or treatment possible, what number would you use to rate all your counseling or treatment in the last 12 months?

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* 31. In the last 12 months, how much were you helped by the counseling or treatment you got?

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* 32. In general, how would you rate your overall mental health now?

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* 33. Compared to 12 months ago, how would you rate your ability to deal with daily problems now?

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* 34. Compared to 12 months ago, how would you rate your ability to deal with social situations now?

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* 35. Compared to 12 months ago, how would you rate your ability to accomplish the things you want to do now?

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* 36. Compared to 12 months ago, how would you rate your problems or symptoms now?

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* 37. The next questions ask about your experience with the company or organization that handles your benefits for counseling or treatment.

 

In the last 12 months, did you use up all your benefits for counseling or treatment?

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* 38. At the time benefits were used up, did you think you still needed counseling or treatment?

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* 39. Were you told about other ways to get counseling, treatment, or medicine?

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* 40. In the last 12 months, did you need approval for any counseling or treatment?

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* 41. In the last 12 months, how much of a problem, if any, were delays in counseling or treatment while you waited for approval?

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* 42. In the last 12 months, did you call customer service to get information or help about counseling or treatment?

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* 43. In the last 12 months, how much of a problem, if any, was it to get the help you needed when you called customer service?

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* 44. In the last 12 months, was any of your counseling or treatment for personal problems, family problems, emotional illness, or mental illness?

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* 45. In the last 12 months, was any of your counseling or treatment for help with alcohol use or drug use?

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

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* 47. What is your age now?

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* 48. Are you male or female?

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

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

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* 51. What is your race. Mark one or more.

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* 52. Did someone help you complete the survey?

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

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