2. This form is intended to help the County and its partners assess system gaps, determine possible solutions, and implement appropriate improvements to ensure access for all individuals who utilize the Crisis Stabilization Center (CSC).

   Please complete the form below without using HIPPA information.

6. First Name*
7. Last Name*
9. Agency*
11. Phone Number*
12. Email Address*
16. Date of Interaction*
    Date of Interaction
17. Which side was involved?*

    1. Detox
    2. Mental Health Triage
    3. Unknown
19. Cultural/Ethnic/Disability Issues:
21. Age:
23. What type of experience do you want to share about the CSC?*

    1. Concerning experience
    2. Successful experience
    3. Both concerning and successful experience
    4. Other experience
25. Briefly, describe the interaction and which program was involved (withdrawal management/detox or mental health triage).*
27. If there is a concern, what steps have you already taken to address your concerns?
29. If there is a concern, what was the outcome?
31. If there is a concern, what are your thoughts about how this type of situation could be addressed more effectively?
33. Successful experiences are important feedback. Which elements of your interaction with the CSC went well?
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field