DSAMH Consumer Survey (Version 2.32, February 2003) Treatment Unit ID: Date: In order to provide the best possible behavioral health services, we need to know what you think about the services you received at this agency during the last year, the people who provided it, and the results. There is space at the end of the survey to comment on any of your answers. Please indicate your agreement/ disagreement with each of the following statements by circling the number that best represents your opinion. If the question is about something you have not experienced, circle the number 9, to indicate that this item is "not applicable" to you. Strongly Disagree Disagree I am Neutral Agree Strongly Agree Not Applicable 1. I like the services that I received here. 1 2 3 4 5 9 2. If I had other choices, I would still get services from this agency. 1 2 3 4 5 9 3. I would recommend this agency to a friend or family member. 1 2 3 4 5 9 4. The location of services was convenient (parking, public transportation, distance, etc.). 1 2 3 4 5 9 5. Staff were willing to see me as often as I felt it was necessary. 1 2 3 4 5 9 6. Staff returned my call in 24 hours. 1 2 3 4 5 9 7. In a time of crisis my case manager or counselor can be easily contacted. 1 2 3 4 5 9 8. Services were available at times that were good for me. 1 2 3 4 5 9 9. I was able to get all the services I thought I needed. 1 2 3 4 5 9 10. I was able to see a psychiatrist when I wanted to. 1 2 3 4 5 9 11. Staff here believe that I can grow, change and recover. 1 2 3 4 5 9 12. I felt comfortable asking questions about my treatment and medication. 1 2 3 4 5 9 13. I felt free to complain 1 2 3 4 5 9 14. I was given information about my rights. 1 2 3 4 5 9 15. Staff encouraged me to take responsibility for how I live my life. 1 2 3 4 5 9 16. Staff told me what side effects to watch out for. 1 2 3 4 5 9 DSAMH Consumer Survey (Version 2.32, February 2003) In order to provide the best possible behavioral health services, we need to know what you think about the services you received at this agency during the last year, the people who provided it, and the results. There is space at the end of the survey to comment on any of your answers. Strongly Disagree Disagree I am Neutral Agree Strongly Agree Not Applicable 17. Staff respected my wishes about who is and who is not to be given information about my treatment. 1 2 3 4 5 9 18. I, not staff, decided my treatment goals. 1 2 3 4 5 9 19. Staff were sensitive to my cultural background (race, religion, language, etc.) 1 2 3 4 5 9 20. The Staff treat people of my race with dignity. 1 2 3 4 5 9 21. The Staff treat people who may be gay or lesbian with dignity. 1 2 3 4 5 9 22. Staff helped me obtain the information I needed so that I could take charge of my managing my illness. 1 2 3 4 5 9 23. I was encouraged to use consumer-run programs (support groups, drop-in centers, crisis phone line, etc.). 1 2 3 4 5 9 As a Direct Result of Services I Received: 24. I deal more effectively with daily problems. 1 2 3 4 5 9 25. I am better able to control my life. 1 2 3 4 5 9 26. I am better able to deal with crisis. 1 2 3 4 5 9 27. I am getting along better with my family. 1 2 3 4 5 9 28. I do better in social situations. 1 2 3 4 5 9 29. I do better in school and/or work. 1 2 3 4 5 9 30. I am better able to get and keep a job. 1 2 3 4 5 9 31. My housing situation has improved. 1 2 3 4 5 9 32. My symptoms are not bothering me as much. 1 2 3 4 5 9 Please feel free to use this space to comment on any of your answers. Also, if there are areas which were not covered by this questionnaire which you feel should have been, please write them here. Thank you for your time and cooperation in completing this questionnaire. The following section is optional and will only be used for statistical compilation purposes. Year of Birth: Gender: (check one) (1)Male _____ (2)Female _____ Race: (check one) _____ (1)African-American _____ (2)African-American plus other races _____ (3)American Indian/Alaskan Native _____ (4)American Indian/Alaskan Native plus other races _____ (5)Asian _____ (6)Asian plus other races _____ (7)Caucasian _____ (8)Caucasian plus other races _____ (9)Native Hawaiian/Other Pacific Islander _____ (10)Native Hawaiian/Other Pacific Islander plus other races _____ (11)Multi-Racial Hispanic/Latino: (check one) _____ (1)Not of Hispanic Origin _____ (2)Cuban _____(3)Mexican _____ (4)Puerto Rican _____(5)Other Hispanic Was your referral to this program a result of Criminal Justice System involvement? (1)Yes___ (2)No___ ˙ext Box: 1˙ext Box: 9˙ext Box: Example:˙ext Box: Interviewer signature________________________________________________________