1. Gender

2. Age

3. Race

4. Do you have Medicaid insurance?

5. As a direct result of the services I received:

I am better able to deal with crisis.

6. My symptoms are not bothering me as much.

7. The medications I am taking help me control symptoms that used to bother me.

8. I do better in social situations.

9. I deal more effectively with daily problems.

10. During my hospital stay

I was treated with dignity and respect.

11. Staff here believed that I could grow, change and recover.

12. I felt comfortable asking questions about my treatment and medications.

13. I was encouraged to use self-help/support groups.

14. I was given information about how to manage my medication side effects.

15. My other medical conditions were treated.

16. I felt this hospital stay was necessary.

17. I felt free to complain without fear of retaliation.

18. I felt safe to refuse medication or treatment during my hospital stay.

19. My complaints and grievances were addressed.

20. I participated in planning my discharge.

21. Both I and my doctor or therapist (from the community) was actively involved in my hospital treatment plan.

22. I had an opportunity to talk with my doctor or therapist from the community prior to discharge.

23. The surroundings and atmosphere at the hospital helped me get better.

24. I felt I had enough privacy in the hospital.

25. I felt safe while I was in the hospital.

26. The hospital environment was clean and comfortable.

27. Staff was sensitive to my cultural background.

28. My family and/or friends were able to visit me.

29. I had a choice of treatment options.

30. My contact with my Doctor was helpful.

31. My contact with nurses and therapists was helpful.

32. If I had a choice of hospitals, I would still choose this one.

33. I am completing this survey at discharge?

34. Please answer the following questions to let us know a little about you.

Length of Stay (This episode)

35. Marital Status

36. Legal Status