Form CMS-10432 PIX Survey

YPX Insights | Psychiatry Inpatient
Directions: Please answer each statement based on your current hospitalization experience. If a question does not apply to you, please
select "Does not apply." We encourage you to answer truthfully and candidly.

Treatment Team Relationship

Strongly
Agree

Agree

Neutral

Disagree

Strongly
Disagree

Does
Not
Apply

Strongly
Agree

Agree

Neutral

Disagree

Strongly
Disagree

Does
Not
Apply

Strongly
Agree

Agree

Neutral

Disagree

Strongly
Disagree

Does
Not
Apply

Strongly
Agree

Agree

Neutral

Disagree

Strongly
Disagree

Does
Not
Apply

My Doctor/Provider treated me with care and respect.
My Doctor/Provider valued my opinion even if we didn't always agree.
My Doctor/Provider helped me understand my treatment options.
I had input into decisions about my treatment.
My Social Worker helped me include family or other supports in my
treatment if I wished.

Environment
The unit was clean.
I felt physically safe on the unit.
I had access to quiet space if I needed it.
Healthy food options were available.
I had enough access to fresh air and/or natural light.
I was satisfied with the services available on the weekends.
I was supported in keeping busy and finding social/recreational activities.

Treatment Effectiveness
The symptoms/problems that brought me to the hospital have improved.
Group therapy was helpful.
I have skills to help manage symptoms/problems I face in daily life.
My medications will help me.
I will have the resources I need to be successful after I leave the hospital.

Nursing Team Presence
Nurses were caring and respectful.
Counselors/Technicians were caring and respectful.
Nurses were attentive to my needs.
Counselors/Technicians were attentive to my needs.
Staff paid attention to what was happening on the unit.
Staff worked together to care for me.

© 2022. All rights reserved.

YPX Insights | Psychiatry Inpatient
Demographic Questions [Optional]

Suggested Item Choices

Did you receive assistance completing this survey?

Yes
No

Age

12 – 17
18 – 24
25 – 34
35 – 44
45 – 54
55 – 64
65 – 74
75 and over

Gender

Female
Male
Transgender Male
Transgender Female
Non-binary
Other
Prefer Not to Say

Sexual Orientation

Heterosexual/Straight
Homosexual/Gay
Homosexual/Lesbian
Bisexual
Other
Prefer Not to Say

Race/Ethnicity

Asian/Pacific Islander
Black or African American
Hispanic or Latino
Native American or American Indian
Biracial/Multiracial
White
Other
Prefer Not to Say

Disability Status

None
Deaf or Hearing Problems
Blind or Vision Problems
Learning Difficulty
Difficulty Walking
Difficulty Thinking/Remembering
Other
Prefer Not to Say

© 2022. All rights reserved.