CHD Clinic Survey (CAHPS® Visit Survey 2.0) Question Title * 1. Our records show that you receive care from a therapist or prescriber.. Is that right? Yes No Question Title * 2. From which CHD clinic(s) do you receive services Pine Street (Springfield) Park Street (West Springfield) State Street (Springfield) Appleton Street (Holyoke) Easthampton Greenfield Orange Athol Greenfield In Home Therapy/Therapeutic Mentoring West Springfield In Home Therapy/Therapeutic Mentoring Easthampton In Home Therapy/Therapeutic Mentoring Question Title * 3. Do you see a therapist, a prescriber (for medication), or both? Therapist only Prescriber only Both Question Title * 4. How long have you been going to this CHD clinic? Less than 6 months At least 6 months but less than 1 year At least 1 year but less than 3 years At least 3 years but less than 5 years 5 years or more Question Title * 5. In the last 12 months, how many times did you visit a CHD clinic? 1 time 2 to 5 6-10 11-15 16-20 21 or more times Question Title * 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? Never Sometimes Usually Always Question Title * 7. In the last 12 months, did you make any appointments for a check-up or routine care with therapist or prescriber? Yes No Question Title * 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? Never Sometimes Usually Always Question Title * 9. In the last 12 months, did you phone your therapist or prescriber’s office with a question after regular office hours? Yes No Question Title * 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? Never Sometimes Usually Always Question Title * 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? Yes No Question Title * 12. During your most recent visit, did your therapist or prescriber explain things in a way that was easy to understand? Yes, definitely Yes, somewhat No Question Title * 13. During your most recent visit, did your therapist or prescriber listen carefully to you? Yes, definitely Yes, somewhat No Question Title * 14. During your most recent visit, did your therapist or prescriber give you easy to understand information about your questions or concerns? Yes, definitely Yes, somewhat No Question Title * 15. During your most recent visit, did your therapist or prescriber seem to know the important information about your mental health history? Yes, definitely Yes, somewhat No Question Title * 16. During your most recent visit, did your therapist or prescriber show respect for what you had to say? Yes, definitely Yes, somewhat No Question Title * 17. During your most recent visit, did your therapist or presecriber spend enough time with you? Yes, definitely Yes, somewhat No Question Title * 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 . . 10 Best provider possible . 9 . 8 . 7 . 6 . 5 . 4 . 3 . 2 . 1 . 0 Worst provider possible Question Title * 19. Would you recommend this CHD clinic to your family and friends? Yes, definitely Yes, somewhat No Question Title * 20. During your most recent visit, were clerks and receptionists at this office as helpful as you thought they should be? Yes, definitely Yes, somewhat No Question Title * 21. During your most recent visit, did clerks and receptionists at this office treat you with courtesy and respect? Yes, definitely Yes, somewhat No Question Title * 22. In general, how would you rate your overall health? Excellent Very good Good Fair Poor Question Title * 23. In general, how would you rate your overall mental or emotional health? Excellent Very good Good Fair Poor Question Title * 24. What is your age? 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 or older Question Title * 25. Are you male or female? Male Female Question Title * 26. What is the highest grade or level of school that you have completed? 8th grade or less Some high school, but did not graduate High school graduate or GED Some college or 2-year degree 4-year college graduate More than 4-year college degree Question Title * 27. Are you of Hispanic or Latino origin or descent? Yes, Hispanic or Latino No, not Hispanic or Latino Question Title * 28. What is your race? Mark one or more. White Black or African American Asian Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Other Question Title * 29. Did someone help you complete this survey? Yes No Question Title * 30. How did that person help you? Mark one or more. Read the questions to me Wrote down the answers I gave Answered the questions for me Translated the questions into my language Helped in some other way Done