This Web site is a component of the SAMHSA Health Information Network
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This Web site is a component of the SAMHSA Health Information Network |
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This Web site is a component of the SAMHSA Health Information Network. |
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Evidence-Based Practices: Shaping Mental Health Services Toward RecoveryCo-Occurring Disorders:
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| Age: ____ 16 - 25 ____ 26 - 35 ____ 36 - 45 ____ 46 - 55 ____ 56 - 65 ____ Over 65 |
Gender: ____ Female ____ Male |
Race or Ethnic group: ____ American Indian or Alaskan Native ____ Asian/Pacific Islander ____ Black/African American ____ Hispanic ____ White ____ Multiple Race/Ethnicity |
Some services offered by the Mental Health Center are listed below. Please make a check mark by the services that you have used:
| ____Case Management ____Partial Hospital ____Educational Services |
____Medication Services ____Vocational Services ____Compeer |
____Psychosocial Services ____Attendant Care ____Other |
INSTRUCTIONS: There are no right or wrong answers. Please answer each question by CIRCLING the number of the choice which matches your opinion at the present time. (Note: The response, "Does Not Apply", means that you have not used this service or the service is not available where you live.)
| Please circle the one choice that best describes your opinion for each statement. | 5 Strongly Agree |
4 Agree |
3 In Between |
2 Disagree |
1 Strongly Disagree |
0 Does Not Apply |
| 1. I have good access to the program (distance, public transportation, parking, etc.) | …5… | …4… | …3… | …2… | …1… | …0… |
| 2. As a result of the services I have received here, I deal more effectively with daily problems. | …5… | …4… | …3… | …2… | …1… | …0… |
| 3. I believe that the staff have my best interest in mind. | …5… | …4… | …3… | …2… | …1… | …0… |
| 4. If I am having a problem with my case manager, the program will make staff changes. | …5… | …4… | …3… | …2… | …1… | …0… |
| 5. I am rarely lonely or bored. | …5… | …4… | …3… | …2… | …1… | …0… |
| 6. The doctor here listens to my concerns and values my opinion. | …5… | …4… | …3… | …2… | …1… | …0… |
| 7. The program's services and staff help me to stay out of the hospital. | …5… | …4… | …3… | …2… | …1… | …0… |
| 8. As a result of the services I have received here, I am better able to deal with crisis. | …5… | …4… | …3… | …2… | …1… | …0… |
| 9. I am free to make choices about my life without fear of losing the help I get from the program. | …5… | …4… | …3… | …2… | …1… | …0… |
| 10. If I have an emergency at night or on the weekend, I am able to get help from the program. | …5… | …4… | …3… | …2… | …1… | …0… |
| 11. Staff follow through on promises they make. | …5… | …4… | …3… | …2… | …1… | …0… |
| 12. I can choose where I live. | …5… | …4… | …3… | …2… | …1… | …0… |
| 13. Staff do a good job of telling me about my rights as a consumer. | …5… | …4… | …3… | …2… | …1… | …0… |
| 14. My opinions and ideas are included in my treatment plan. | …5… | …4… | …3… | …2… | …1… | …0… |
| 15. The staff here treat me like an adult, not a child. | …5… | …4… | …3… | …2… | …1… | …0… |
| 16. The staff help to overcome the problems that go along with getting and keeping a job. | …5… | …4… | …3… | …2… | …1… | …0… |
| 17. To the best of my knowledge, staff have kept my personal information confidential. | …5… | …4… | …3… | …2… | …1… | …0… |
| 18. As a result of the services I have received here, I do better with my leisure time. | …5… | …4… | …3… | …2… | …1… | …0… |
| 19. Overall, I am satisfied with the services I receive. | …5… | …4… | …3… | …2… | …1… | …0… |
| 20. If I don't want the services the staff recommend, they will give me other choices. | …5… | …4… | …3… | …2… | …1… | …0… |
| 21. The staff I work with are competent and knowledgeable. | …5… | …4… | …3… | …2… | …1… | …0… |
| 22. Staff have helped me to maintain a home or apartment in the community. | …5… | …4… | …3… | …2… | …1… | …0… |
| 23. I know who the consumer representative is on the Mental Health Center's Governing Board. | …5… | …4… | …3… | …2… | …1… | …0… |
| 24. As a result of the services I have received here, I do better in social situations. | …5… | …4… | …3… | …2… | …1… | …0… |
| 25. Staff are willing to see me as often as I feel it is necessary. | …5… | …4… | …3… | …2… | …1… | …0… |
| 26. My doctor tries to find the medications that work best for me. | …5… | …4… | …3… | …2… | …1… | …0… |
Please give us any comments you would like to make about what you like and dislike about the services you receive, and suggestions for how to make things better.
(You may attach additional pages if more space is needed for comments.)
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