For 24/7 referrals please contact us at - Phone: (225) 663-2881 Fax: (225) 355-1555

REFERRAL NEEDS ASSESSMENTPrint

Name / Referral Source:
Address:
City: State: Zip Code:
Phone #: Fax #:
If applicable, please provide updated information for our records:
Administrator: DON:
Social Services Director: Medical Director:
Physicians Office Manager: Nurse:
Case Manager(s)

This tool is to ensure the quality of service that Apollo Behavioral Health Hospital thrives to give to each of its referral sources. We look forward to improving our services and assisting you with your clients:

1
Bad
2
Poor
3
Average
4
Good
5
Excellent
1. Was your call answered in a quick and courteous manner?  Bad Poor Average Good Excellent
2. Was an assessment offered for your client?  Bad Poor Average Good Excellent
3. If assessment completed, was it done from start to finish?  Bad Poor Average Good Excellent
4. Were you contacted during your clients stay by a representative?  Bad Poor Average Good Excellent
5. Was discharge paperwork adequate and readable?  Bad Poor Average Good Excellent
6. Did client arrive back to your facility at an appropriate time?  Bad Poor Average Good Excellent
7. Was transportation offered for your client?  Bad Poor Average Good Excellent
8. How would you rate your overall satisfaction with Apollo Behavioral?  Bad Poor Average Good Excellent
9. Would you continue to refer to Apollo Behavioral for your clients needs?  Yes No
Comments related to services received by your patients:
Needs Assessment
What are your inpatient and outpatient needs for your clients?
How often do you utilize these types of services?
What can Apollo Behavioral Health Hospital do to better serve your patients psychiatric needs?
Apollo Behavioral Health Hospital offers many services to your patients. Are there any other services that would make the referral /treatment/discharge/After Care process easier for you?

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