OTP Intake Survey

1
In which state was the facility you attended located?* This field is required.
Please Select
Please Select
California
Georgia
Indiana
Kentucky
New Jersey
North Carolina
Ohio
Pennsylvania
Virginia
2
Which location did you attend for your intake?
Please Select
Please Select
Aegis - Atascadero
Aegis - Auburn
Aegis - Bakerfield 21st Street
Aegis - Bakerfield Columbus
Aegis - Bakersfield Truxton
Aegis - Banning
Aegis - Barstow
Aegis - Ceres
Aegis - Chico
Aegis - Delano
Aegis - El Monte
Aegis - Eureka
Aegis - Fresno
Aegis - Grass Valley
Aegis - Hesperia
Aegis - Inglewood
Aegis - La Miranda
Aegis – Lodi
Aegis - Los Banos
Aegis - Madera
Aegis - Manteca
Aegis - Marysville
Aegis - Merced
Aegis - Modesto
Aegis - Ontario
Aegis - Oxnard
Aegis - Pasedena
Aegis - Placerville
Aegis - Pomona
Aegis - Redding
Aegis - Redlands
Aegis - Ridgecrest
Aegis - Roseville
Aegis - San Luis Obispo
Aegis - Santa Barbara
Aegis - Santa Maria
Aegis - Santa Paula
Aegis - Simi Valley
Aegis - Sonora
Aegis - Stockton 5th St
Aegis - Stockton California St
Aegis - Stockton Lower Sacremento
Aegis - Tracy
Aegis - Turlock
Aegis - Ventura
Aegis - West Covina
Aegis - Wilmington
California
3
Which location did you attend for your intake?
Please Select
Please Select
HealthQwest - Buford
HealthQwest - Canton
HealthQwest - Douglasville
HealthQwest - Macon
HealthQwest - Savannah
HealthQwest - Stockbridge
HealthQwest - Warner Robins
Georgia
4
Which location did you attend for your intake?
Please Select
Please Select
Martinsville Treatment Services
Kokomo Treatment Services
Indiana
5
Which location did you attend for your intake?
Please Select
Please Select
Carrollton Counseling
Davis Treatment Center
Georgetown Medical
Maysville Medical
NKY Med Clinic
Simpson Treatment Services
Western KY Medical
Winchester Treatment Services
Kentucky
6
Which location did you attend for your intake?
Please Select
Please Select
Delaware Valley Medical
Hamilton Treatment Services
Lacey Treatment Services
Middletown Medical
Ocean Medical Services
Ocean Monmouth Care
Somerdale Treatment Services
Stateline Medical
Trenton Treatment Services
Vineland Treatment Services
New Jersey
7
Which location did you attend for your intake?
Please Select
Please Select
Stepping Stone of Boone
Stepping Stone of Wilkes
North Carolina
8
Which location did you attend for your intake?
Please Select
Please Select
Akron Treatment Services
Athens Treatment Services
Brilliant Treatment Services
Chillicothe Treatment Services
Covedale Treatment Services
Dayton Treatment Services
Elyria Treatment Services
Findlay Treatment Services
Georgetown Treatment Services
Hamilton Treatment Services
Marion Treatment Services
Milford Treatment Services
Niles Treatment Services
Sandusky Treatment Services
Springfield Treatment Services
Toledo Treatment Services
Youngstown Treatment Services
Zanesville Treatment Services
Ohio
9
Which location did you attend for your intake?
Please Select
Please Select
Alliance Medical Services - Johnstown
Alliance Medical Services of Pittsburgh - Ensign I
Alliance Medical Services of Pittsburgh - Ensign II
Charleroi Treatment Services
Greenfield Counseling
Hanover Treatment Services
Hazleton Treatment Services
Lansdowne Treatment Services
Miners Medical
Mount Pocono Medical
Northeast Family Healthcare
Pinnacle Treatment Services of Aliquippa
State College Medical
Summit Medical Services
Williamsport Family Medical
Pennsylvania
10
Which location did you attend for your intake?
Please Select
Please Select
American Addiction Treatment Center - Hayes
American Addiction Treatment Center - Newport News
American Addiction Treatment Center - Williamsburg
Culpeper Treatment Services
FCCR - Fredericksburg
FCCR - Radford
FCCR - Southlake
Front Royal Treatment Center
Martinsville Treatment Services
Pulaski Medical
Virginia
11
How did you schedule your intake?* This field is required.
Pinnacle Call Center
Called Facility
Walked In (No Appointment)
Self-Scheduled on Website
Other
12
How satisfied were you with the intake scheduling process?* This field is required.
Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Dissatisfied
13
How satisfied were you with the intake scheduling process (score)
14
Did you feel welcomed by the staff at the facility?* This field is required.
Agree
Somewhat Agree
Somewhat Disagree
Disagree
Front Desk
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Counselors/Case Managers
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Nursing
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Doctor/Nurse Practitioner/Physician Assistant
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Front Desk
Counselors/Case Managers
Nursing
Doctor/Nurse Practitioner/Physician Assistant
Agree
Row 0, Column 0
Somewhat Agree
Row 0, Column 1
Somewhat Disagree
Row 0, Column 2
Disagree
Row 0, Column 3
Agree
Row 1, Column 0
Somewhat Agree
Row 1, Column 1
Somewhat Disagree
Row 1, Column 2
Disagree
Row 1, Column 3
Agree
Row 2, Column 0
Somewhat Agree
Row 2, Column 1
Somewhat Disagree
Row 2, Column 2
Disagree
Row 2, Column 3
Agree
Row 3, Column 0
Somewhat Agree
Row 3, Column 1
Somewhat Disagree
Row 3, Column 2
Disagree
Row 3, Column 3
1 of 4
15
Welcomed Front Desk Score
16
Welcomed Counselor Score
17
Welcomed Nursing Score
18
Welcomed Doctor Score
19
Were you satisfied with the cleanliness and appearance of the facility?* This field is required.
Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Dissatisfied
20
Cleanliness Score
21
How long was your intake?* This field is required.
Less than 1 Hour
1-2 Hours
2-3 Hours
4-5 Hours
More than 5 Hours
22
Intake Length Score
23
Overall, how satisfied were you with the intake process?* This field is required.
Satisfied
Somewhat Satisfied
Somewhat Dissatisfied
Dissatisfied
24
Overall Intake Satisfaction Score
25
Any suggestions to improve the intake experience?
Huge
Large
Normal
Small
Ok
Ok
26
Please verify that you are human* This field is required.
Should be Empty: