Delaware Health and Social Services
Division of Substance Abuse and Mental Health
Consumer Status Survey
Survey Information Effective as of June 30, 2004
Confine answer to line, box or circle provided
		

Fill in circle or box for each selected answer

Page 1 of 3

Consumer Status Survey.doc	8/5/2004	

Consumer’s Name:Last Name              First Name	       M.I.						

Treatment Unit ID Number
														
MCI Number
						
Month  06  Day	30  Year 2004 

Person Completing Form: ________________________________   
Supervisor Verification: ________________________________  

A.Does the Consumer have a regular place to live where	    	YES	NO
      he/she spends at least 5 out of 7 nights on average?	 O  1.	O  2.

B.  How many places has the Consumer lived in the past 90 days?
 O  1.  O  2.  O  3.  O  4.  O  5.  O  6.  O  7. O  8.  O  > 9.

C. Was the Consumer active in an Assertive Community Treatment (ACT) program on June 30, 2004?  
 O  1.YES           O  2. NO 

D. What was the Consumer’s residential arrangement on June 30, 2004?                                                                                                        Mark only one answer.
Private Residence / Unsupervised			O   1.
Private Residence / Supervised				O   1.
Licensed Adult Foster Care				O   1.
Unlicensed Adult Foster Care				O   1.
Boarding Home						O   1.
Group Home Setting / Unsupervised			O   1.
Group Home Setting / Supervised				O   1.
Nursing Home, ICF / SNF					O   1.
Corrections Facility / Jail				O   1.
Psychiatric Hospital > 180 days				O   1.
Psychiatric Ward / General Hospital > 180 Days		O   1.
Other Institution					O   1.
No Domicile / Homeless					O   1.
Emergency Housing, Shelter < 30 Days			O   1.
Transitional Housing > 30 Days				O   1.
Crisis Residence					O   1.
Other							O   1.
Unknown							O   1.
        


DSAMH Consumer Status Survey (continued; p.2)
Survey Information Effective as of June 30, 2004 
Fill in circle for selected answer 


E. Has the consumer been homeless in the past 12 months?   Yes  O  1.	  No  O  2.

F. This list refers to the facilities and appliances available to the consumer where
     he / she lives. Are they available in working condition?	  YES	NO
					YES	NO
Bathroom Facilities			O  1.  O  2.
Room where he / she can go to be alone	O  1.  O  2.
Range / Cooking Stove – not hot plate	O  1.  O  2.
Refrigerator				O  1.  O  2.
Telephone				O  1.  O  2.
Washer / Dryer				O  1.  O  2.

G. Consumer’s Housing Subsidy on June 30, 2004.   Select only one answer.
    (Note: Consumers residing in Mental Health group homes should check item #3.)
    	O   	1.  State / Federal Subsidized Housing
    	O	2.  Subsidized with Client Assistance Funds
	O	3.  No Rental Subsidy

H. How safe is the consumer’s Neighborhood from crime? Select only one answer.
	O	1.  Very Safe – Crime is minor and rare 
      	O	2.  Safe if careful – Crime is minor and infrequent
	O	3.  Not Safe – Crime is minor and major, but infrequent
	O	4.  Very Unsafe – Crime is minor and major and frequent

I.  Does the consumer have enough money each month to cover the following?
								YES	NO
Food								O  1.  O  2.
Clothing							O  1.  O  2.
Rent								O  1.  O  2.
Necessary Travel (work, shopping, medical appointments, etc.)	O  1.  O  2.
Medical Care							O  1.  O  2.
Traveling to visit friends					O  1.  O  2.
Social Activities (movies, eating in restaurants, etc.) 	O  1.  O  2.



DSAMH Consumer Status Survey (continued; p.3)
Survey Information Effective as of June 30, 2004
Fill in circle for selected answer


J.  Consumer’s Primary Activity on June 30, 2004. Select only one answer. 
  O   1.  Full Time (Paid) >37.5 hrs per week	O   8.   Student
  O   2.  Part Time (Paid) <37.5 hrs per week	O   9.   Retired
  O   3.  Military / Armed Forces		O  10.  Inmate / Resident of Institution
  O   4.  Unemployed / Looking for Work		O  11.  Volunteer
  O   5.  Unemployed/Not Looking for Work	O  12.   Other
  O   6.  Disabled / Unable to Work		O  13.  Unknown
  O   7.  Homemaker	

K.  Consumer’s Primary Paid Employment Type on June 30, 2004. Select only one. 
 O 1. Sheltered 				O 3. Competitive / Supported
 O 2. Competitive / Not Supported		O 4. Not working

L.  On average how many hours per week has the consumer spent on their 
	primary activity during the past 90 days?  __ __

M.  On June 30, 2004, was the consumer receiving treatment on an inpatient basis at a psychiatric facility? – Select one answer.
O   1. Yes, Psychiatric Hospital (e.g. DPC, Rockford, Meadowood) 
O   2. Yes, Psychiatric Ward / General Hospital (e.g. BayHealth,Christiana Hospital)
O   3. No

N.  Has the Consumer Received the any of the following services in the past year? 
  O   1.  Supported Housing	
  O   2.  Supported Employment		
  O   3.  Assertive Community Treatment	
  O   4.  Family Psychoeducational
  O   5.  Integrated Treatment for Co-Occurring Disorders	
  O   6.  Illness Management / Recovery 

O.  How many times in the past twelve months has the consumer been arrested?  	__ __
	
P.   Raters confidence in the information.
O   1.    This information is known about the consumer
O   2.    This is a guesstimate, please indicate confidence level (0 – 100%)	__ __ __