<p>Your clinic logo here</p><p>MEDICAL PROVIDER SATISFACTION SURVEY BEHAVIORAL HEALTH CONSULTATION PROGRAM</p><p>1. How long have you been working at (clinic name)? ______Years (or Months)</p><p>2. How satisfied are you with the ability of the medical team to address the needs of patients with mental disorders, addictions and other psychosocial problems? (circle one)</p><p>Not at all satisfied Slightly satisfied Somewhat satisfied Pretty Satisfied Extremely Satisfied</p><p>3. In general, how effective are you in addressing such issues as mental disorders, addictions and other psychosocial concerns in medical exams? (circle one)</p><p>Not at all effective Slightly effective Somewhat effective Pretty effective Extremely effective</p><p>4. In general, how confident are you in your ability to use behavior change interventions as a first line response to mental disorders, addictions and other psychosocial concerns, in lieu of or in combination with medicines? (circle one)</p><p>Not confident at all Slightly confident Somewhat confident Pretty Confident Extremely Confident</p><p>5. In general, how effective do you feel in addressing patients with low motivation to change, patients who are not making needed behavior changes or patients that are not adhering to their medical treatment? (circle one)</p><p>Not effective at all Slightly effective Somewhat effective Pretty effective Extremely effective</p><p>6. In general, describe the impact that addressing issues such as mental disorders, addictions, psychosocial concerns, motivational deficits and medical non-adherence has upon your satisfaction with your medical practice. (check one)</p><p>____It has a very negative impact on my satisfaction with medical practice ____It has a negative impact on my satisfaction with medical practice ____It has no impact on my satisfaction with medical practice ____It has a positive impact on my satisfaction with medical practice ____It has a very positive impact on my satisfaction with medical practice</p><p>7. How much have you used the Behavioral Health Consultant? (circle one)</p><p>Not at All Very Little Some, But Not A Lot Quite A Bit A Lot</p><p>1 Clinic Code: IF YOU HAVE NOT USED THE BEHAVIORAL HEALTH CONSULTANT AT ALL, STOP HERE – STILL RETURN YOUR SURVEY 8. How would you rate your satisfaction with access to behavior health consultations? (circle one)</p><p>Poor Fair Good Very Good Excellent</p><p>9. Does the BHC provide the kinds of services you want for your patients? (circle one)</p><p>No, definitely not Only occasionally Most of the time Yes, definitely</p><p>10. In your perception, how helpful have the behavioral health consultations been for your patients? (circle one)</p><p>Not helpful Mildly helpful Somewhat helpful Very helpful Extremely helpful</p><p>11. Thinking about your consultations with the BHC, how helpful are these consultations to you as the medical provider? (circle one)</p><p>Not helpful Mildly helpful Somewhat helpful Very helpful Extremely helpful</p><p>12. Thinking about your communications with the BHC in your clinic, how would you rate the timeliness of the BHC’s feedback? (circle one)</p><p>Poor Fair Good Very Good Excellent</p><p>13. Overall, how would you rate the quality of the behavioral health consultation services provided to you and your patients? (circle one)</p><p>Poor quality Fair quality Acceptable quality Good quality Excellent quality</p><p>14. All things considered, how satisfied are you with having BHC services in your clinic? (circle one)</p><p>Completely Very Somewhat Neither Somewhat Very Completely Dissatisfied Dissatisfied Dissatisfied Dissatisfied Satisfied Satisfied Satisfied Nor Satisfied</p><p>15. Based on your experiences with the behavioral health consultation service in your clinic, would you recommend to your medical colleagues that they use this service with their patients? (circle one)</p><p>Definitely Not Probably Not Probably Yes Definitely Yes</p><p>16. Do you think having a behavioral health consultations service has improved your willingness to recognize, assess, and treat the behavioral health problems of your patients? (circle one)</p><p>Not at All A Little Bit Somewhat Quite a Bit A Lot</p><p>14. In your opinion, what is/are the most important and useful aspects of Behavioral Health Consultant Services? </p><p>2 3 Clinic Code: </p>