Timberlawn Mental Health System, Dallas, Texas

Referral Source Satisfaction Survey

Our mission at Timberlawn Mental Health System focuses on the delivery of quality services to all of our customers. Your feedback and input will assist us in reaching this very important goal. Please take a moment to complete the survey. Thank you!

* Astericked fields and questions are required.

*Name:
*City:
*Phone:
*Fax:

For the questions below, 1=Least Helpful, 5=Most Helpful.

Intake and Admission Process (Please rate the overall process)		1	2	3	4	5
*1.	Was your call answered or returned promptly?
*2.	Were you treated in a courteous and professional manner?
*3.	Were you satisfied with the information offered to you?
*4.	Were you satisfied with the outcome of the assessment?
*5.	Did someone notify you with the disposition of the assessment?

Treatment Team (Please rate the overall process)		1	2	3	4	5
*1.	Were you contacted by program staff within 48 business hours?
*2.	Did you receive the treatment information you requested?
*3.	Did our therapists give you treatment updates as requested?

Discharge Planning (Please rate the overall process)		1	2	3	4	5
*1.	Were you involved in the discharge planning process?
*2.	Did the staff assist you with scheduling the follow up appointment?
*3.	Were you notified prior to the clients release from Timberlawn?
*4.	Did you receive the information you needed from us at the time of discharge?

*Please rate our performance overall.

*I will continue to refer clients to Timberlawn.	Yes	No
*I would like a Timberlawn Representative to call me.	Yes	No

Comments/Suggestions

Become a member of the Timberlawn Network (Receive updates, Brown Bag announcements, newsletters, etc...)

Name:

Address:

Phone:

Fax:

Email:

Please do not use this form, or electronic mail, to discuss your medical condition, medical history, or private health information. It is not encrypted, and we cannot guarantee your privacy if you include sensitive information about yourself.

Copyright� 1999, Timberlawn Mental Health System
4600 Samuell Boulevard, Dallas Texas, 75228, USA | (214) 381-7181 | timberlawn.com