APPENDIX ONE

<Agency>

Client Assessment Worksheet

Program Name

Client Number Date

1. During the last few (2-3) months, how often have you engaged in productive activity? Productive activities include subsistence activities, full or part time employment, volunteer work, church activities, school, sports, or social activity.

c 1 Usually every day

c 2 2 – 5 days a week

c 3 5 – 10 days a month

c 4 1 – 4 days a month

c 5 Not active

2. Which of the following best describes your legal status during the last few (2-3) months?

c 1 No legal involvement at all

c 2 Some non-criminal problems but no threat of jail such as truancy or minor litigation

c 3 Legal issues that are now pending

c 4 Probation, parole, awaiting sentencing or extreme impact, non-criminal problems such as divorce or child custody or attending court-ordered outpatient mental health treatment

c 5 Incarcerated: Lock-up or non-lock-up or mandatory hospitalization

3. During the last few (2-3) months, how would you best describe your feeling of general safety? General safety refers to issues such as domestic violence, homelessness, safety of community or village, reliable transportation, prejudice, or parental discord.

c 1 I feel safe all of the time

c 2 I feel safe most of the time

c 3 I feel safe sometimes but feel unsafe other times

c 4 I feel unsafe most of the time

c 5 I feel unsafe all of the time

4. During the past few (2-3) months, how would you describe your economic security?

c 1 Very secure economically

c 2 I am more often than not economically secure, very few concerns

c 3 Somewhat secure economically, my problems are tolerable

c 4 I am more often than not economically insecure; I have many economic concerns.

c 5 Extreme economic hardship; unable to meet basic life needs

5. During the last few (2-3) months, how would you describe your housing status?

c 1 Independent Living. Most of the time, I owned or rented my own habitable house or apartment; or I chose to live with others.

c 2 Lives with others. Most of the time, I lived with family or others in a custodial relationship where they helped care for me.

c 3 Sheltered care. Most of the time, I lived in a supervised SRO, adult foster home, supported apartment program; or Residential. I lived in a residential program such as a domiciliary, group home, staffed apartment, or halfway house with 24 hour per day, seven days a week supervision.

c 4 Homeless. Most of the time, I was homeless, lived in a shelter or barely habitable, inadequate place.

c 5 Institutional. Most of the time, I lived in a hospital or institution most of the time.

6. Dual diagnosis (substance abuse) is a common problem that often goes along with being mentally ill. We are not here to judge you but to get information that will help improve your treatment. Please answer the following questions:

a. Have friends or relatives asked you to Cut down on alcohol, tobacco, or other drugs, or quit entirely?

c Yes c No

b. Are you Annoyed by friends or relatives who question your use?

c Yes c No

c. Have you experienced Guilt because of your drinking or use?

c Yes c No

d. Do you need an Eye opener in the morning (alcohol, tobacco, or other drugs) to get started?

c Yes c No

To how many of the above questions you answer “Yes”

c 1 I answered “Yes” to none of the questions

c 2 I answered “Yes” to only one of the questions

c 3 I answered “Yes” to two of the questions

c 4 I answered “Yes” to three of the questions

c 5 I answered “Yes” to all four questions

7. During the last six months, how many times have you been hospitalized for mental health treatment?

c 1 None

c 2 1 time

c 3 2 times

c 4 3 times

c 5 4 or more times

8a. Which of the following best describes how you get your regular medical care? Regular health care is defined as health care received from your primary or family physician in a physician’s office or clinic.

c 1 I have access to regular health care all of the time.

c 2 I have access to regular health care most of the time.

c 3 I have access to regular health sometimes but occasionally go to the emergency room or use emergency medical technicians for my health care.

c 4 I have limited access to regular health care and get most of my health care at the emergency room or with emergency medical technicians.

c 5 I do not have access to regular health care. I use the emergency room or emergency medical technicians for all of my health care.

8b. During the last few (2-3) months, how often have physical medical problems interfered with your normal activities?

c 1 Never

c 2 Only a few times in the last six months

c 3 At least once a month

c 4 At least once a week

c 5 Usually every day

9. Which of the following best describes how your health care is paid for?

c 1 I do not have to pay for any of my health care. I am either fully insured (including Medicaid) or receive my health care through an Indian Health Service facility with no charges.

c 2 I have health care insurance (including Medicaid or Medicare) or receive service at an Indian Health Service facility but have to pay for some of the charges myself.

c 3 I have some health care insurance but I have to pay about half of the charges for my health care.

c 4 I have very little health care insurance and I have to pay for most of the costs for my health care.

c 5 I have to pay all of the costs for my health care out of pocket.

Read to consumer:

This is the first time we have used this survey so we would like your opinion about it.

Consumers:

Were any of the questions hard to answer? Which ones? Why?

Were any of the questions unclear? Which ones? Why?

Do you have any other comments? (Use reverse side if needed)

Clinicians: (also please feel free to write any comments about individual questions right next to the questions)

Did consumers have problems with any of the questions? Which questions? What problems?

Were any of the questions unclear? If Yes, please tell us which questions were unclear.

Were there things we did not ask that you feel we should add?

Do you have any other comments?

APPENDIX TWO

<Agency>

Mental Health Consumer Satisfaction Survey (Adult)

Attached to this cover sheet is a consumer survey developed by the Mental Health Statistics Improvement Program (MHSIP). We have added this cover sheet with demographic questions to help us better understand the diverse people that we are serving in Alaska and the impact that services have on our diverse population. Please note that there is no place that asks for your name or any other identifying information. Neither have we placed any codes on the forms or envelopes that would enable someone to identify you. This is a completely anonymous survey.

Demographic Questions

1. Which of these groups includes your age on your last birthday?

c Less than 18 years old c 18 – 22 years old

c 23 – 59 years old c 60 or older

2. Which of the following best describes the race/ethnicity that you consider yourself?

c African American c Alaska Native/American Indian

c Asian/Pacific Islander c Caucasian

c Hispanic/Latino c Other

3. Gender

c Female c Male

4a. Which of the following services have you received in the last year from <agency> (please check all that apply)?

c Therapy/Counseling c Case Management

c Housing Services c Assistance with Employment Issues

c Family Services c Substance Abuse Treatment Services

c Transportation Services c Advocacy Services

c Psychiatric Services/Medication Management

c Other Services (please specify)

4b. Are you still receiving services from <agency>?

c Yes c No

5. How long have you been receiving, or did you receive, services from <agency>?

c Less than six months c 6 months to 2 years

c 2 to 5 years c More than 5 years

6. About how often do (or did) you receive direct services from <agency>?

c Daily c Weekly

c Bi-weekly c Monthly

c Every three months c Other

7. Comments. Is there anything else that you would like to tell us about yourself or the services that receive that might help us to better serve you?

Thank you for taking the time to answer these questions about yourself.

This is the first time we have used this survey so we would like your opinion about it.

1. Were any of the questions hard to understand? Which ones? Why?

2. Were any of the questions unclear? Which ones? Why?

3. Was the questionnaire too long?

4. Did we ask everything that you think is important about mental health services?

5. Are there any questions we should add?

6. Do you have any other comments? (please use the reverse side if needed)

APPENDIX THREE

<Agency>

Demographic Questionnaire (Child & Family)

This sheet is attached to a Consumer Satisfaction Survey developed by the Mental Health Statistics Improvement Program (MHSIP). This demographic information will help us better understand the people we are serving in Alaska and the impact that mental health services have on our diverse population. There is no place that asks for your name or any other identifying information. There are no codes on the forms or envelopes that would enable someone to identify you. This is a completely anonymous survey.

1. In what year were you born? ___________

2. Which of the following best describes the race/ethnicity that you consider yourself?

c African American c Alaska Native/American Indian

c Asian/Pacific Islander c Caucasian

c Hispanic/Latino c Other

3. Gender: c Female c Male

4. Are you (or is the child/adolescent) in protective custody?

c Yes c No

If yes, please select one of the following?

c Division of Family and Youth Services

c Division of Juvenile Justice

c Parent-Guardian

5. Which of the following services have you received in the last year from <agency>? (Please check all that apply)

c Therapy/Counseling c Case Management

c Housing Services c Assistance with Employment Issues

c Family Services c Substance Abuse Treatment

c Transportation Services c Advocacy Services

c Psychiatric Services/Medication c Other:____________________________

6. Are you still receiving services from <agency>? c Yes c No

7. How long have you been receiving, or did you receive, services from <agency>?

c Less than six months c 2 to 5 years

c 6 months to 2 years c More than 5 years

8. About how often do (or did) you receive direct services from <agency>?

c Daily c Once a month

c Twice a week c Every other month

c Once a week c Every three months

c Twice a month c Other ______________________

9. Comments. Is there anything else that you would like to tell us about yourself or the services that you receive that might help us to better serve you? (Please use the reverse side if needed.)

______________________________________________________________________________

This is the first time we have used this survey so we would like your opinion about it.

1. Were any of the questions hard to understand? Which ones? Why?

2. Were any of the questions unclear? Which ones? Why?

3. Was the questionnaire too long?

4. Did we ask everything that you think is important about mental health services?

5. Are there any questions we should add?

6. Do you have any other comments? (please use the reverse side if needed)

APPENDIX FOUR

MHSIP CONSUMER SURVEY
In order to provide the best possible mental health services, we need to know what you think about the services you received, 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 or 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 N/A, to indicate that this item is “not applicable” to you.	Strongly Agree =1	Agree =2	I am Neutral =3	Disagree =4	Strongly Disagree =5	Not Applicable =N/A
1. I like the services that I receive here.	1	2	3	4	5	N/A
2. If I had other options, I would still get services from this agency.	1	2	3	4	5	N/A
3. I would recommend this agency to a friend or family member.	1	2	3	4	5	N/A
4. The location of the services was convenient (parking, public transportation, distance, etc.).	1	2	3	4	5	N/A
5. Staff were willing to see me as often as I felt it was necessary.	1	2	3	4	5	N/A
6. Staff returned my calls within 24 hours.	1	2	3	4	5	N/A
7. Services were available at times that were good for me.	1	2	3	4	5	N/A
8. I was able to get all the services I thought I needed.	1	2	3	4	5	N/A
9. I was able to see a psychiatrist when I wanted to.	1	2	3	4	5	N/A
10. Staff here believe that I can grow, change, and recover.	1	2	3	4	5	N/A
11. I felt comfortable asking questions about my treatment and medication.	1	2	3	4	5	N/A
12. I felt free to complain.	1	2	3	4	5	N/A
13. I was given information about my rights.	1	2	3	4	5	N/A
14. Staff encouraged me to take responsibility for how I live my life.	1	2	3	4	5	N/A
15. Staff told me what side effects to watch out for.	1	2	3	4	5	N/A
16. Staff respected my wishes about who is, and who is not, to be given information about my treatment.	1	2	3	4	5	N/A
17. I, not staff, decided my treatment goals.	1	2	3	4	5	N/A
18. Staff were sensitive to my cultural/ethnic background (race, religion, language, etc.).	1	2	3	4	5	N/A
19. Staff helped me obtain the information I needed so I could take charge of managing my illness	1	2	3	4	5	N/A
20. I was encouraged to use consumer-run programs (support groups, drop-in centers, crisis phone line, etc.).	1	2	3	4	5	N/A

Please indicate your agreement or 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 N/A, to indicate that this item is “not applicable” to you.	Strongly Agree =1	Agree =2	I am Neutral =3	Disagree =4	Strongly Disagree =5	Not Applicable =N/A
As a direct result of the services I received here:
21. I deal more effectively with daily problems.	1	2	3	4	5	N/A
22. I am better able to control my life.	1	2	3	4	5	N/A
23. I am better able to deal with crisis.	1	2	3	4	5	N/A
24. I am getting along better with my family.	1	2	3	4	5	N/A
25. I do better in social situations.	1	2	3	4	5	N/A
26. I do better in school and/or work.	1	2	3	4	5	N/A
27. My housing situation has improved.	1	2	3	4	5	N/A
28. My symptoms are not bothering me as much.	1	2	3	4	5	N/A
29. I experienced no harmful medication side effects.	1	2	3	4	5	N/A
30. I can deal better with people and situations that used to be a problem for me.	1	2	3	4	5	N/A

This is the first time we have used this survey so we would like your opinion about it.

1. Were any of the questions hard to understand? Which ones? Why?

2. Were any of the questions unclear? Which ones? Why?

3. Was the questionnaire too long?

4. Did we ask everything that you think is important about mental health services?

5. Are there any questions we should add?

6. Do you have any other comments? (please use the reverse side if needed)

APPENDIX FIVE

Youth services survey FOR FAMILIES (yss – f)
To improve services to clients, we need to know what you think about the treatment you received, the people who provided it, and the results of this treatment.
Please indicate your agreement or 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 N/A, to indicate that this item is “not applicable” to you.	Strongly Agree =1	Agree =2	I am Neutral =3	Disagree =4	Strongly Disagree =5	Not Applicable =N/A
1. Overall, I am satisfied with the services my child received.	1	2	3	4	5	N/A
As a result of the services my child and/or family received:
2. My child is better at handling daily life.	1	2	3	4	5	N/A
3. My child gets along better with family members.	1	2	3	4	5	N/A
4. My child gets along better with friends and other people.	1	2	3	4	5	N/A
5. My child is doing better in school and/or work.	1	2	3	4	5	N/A
6. My child is better able to cope when things go wrong.	1	2	3	4	5	N/A
7. I am satisfied with our family life right now.	1	2	3	4	5	N/A
Feedback about the services my child and/or family received:
8. I helped to choose my child’s services.	1	2	3	4	5	N/A
9. I helped to choose my child’s treatment goals.	1	2	3	4	5	N/A
10. The people helping my child stuck with us no matter what.	1	2	3	4	5	N/A
11. I felt my child had someone to talk to when he/she was troubled.	1	2	3	4	5	N/A
12. The people helping my child listened to what he/she had to say.	1	2	3	4	5	N/A
13. I was frequently involved in my child’s treatment.	1	2	3	4	5	N/A
14. The services my child and/or family received were right for us.	1	2	3	4	5	N/A
15. The location of services was convenient for us.	1	2	3	4	5	N/A
16. Services were available at times that were convenient for us.	1	2	3	4	5	N/A
17. If I need services for my child in the future, I would use these services again.	1	2	3	4	5	N/A
18. My family got the help we wanted for my child.	1	2	3	4	5	N/A
19. My family got as much help, as we needed for my child.	1	2	3	4	5	N/A
20. My child and family’s needs determined my child’s treatment goals.	1	2	3	4	5	N/A

Please indicate your agreement or 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 N/A, to indicate that this item is “not applicable” to you.	Strongly Agree =1	Agree =2	I am Neutral =3	Disagree =4	Strongly Disagree =5	Not Applicable =N/A
21. Staff treated me with respect.	1	2	3	4	5	N/A
22. Staff understood my family’s cultural traditions.	1	2	3	4	5	N/A
23. Staff respected my family’s religious/spiritual beliefs.	1	2	3	4	5	N/A
24. Staff spoke with me in a way that I understood.	1	2	3	4	5	N/A
25. Staff were sensitive to my cultural/ethnic background.	1	2	3	4	5	N/A
26. I felt we were discriminated against while trying to get services here.	1	2	3	4	5	N/A

This is the first time we have used this survey so we would like your opinion about it.

1. Were any of the questions hard to understand? Which ones? Why?

2. Were any of the questions unclear? Which ones? Why?

3. Was the questionnaire too long?

4. Did we ask everything that you think is important about mental health services?

5. Are there any questions we should add?

6. Do you have any other comments? (please use the reverse side if needed)

Thank you for taking the time to answer these questions!

APPENDIX SIX

Youth services survey (yss)
To improve services to clients, we need to know what you think about the treatment you received, the people who provided it, and the results of this treatment.
Please indicate your agreement or 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 N/A, to indicate that this item is “not applicable” to you.	Strongly Agree =1	Agree =2	I am Neutral =3	Disagree =4	Strongly Disagree =5	Not Applicable =N/A
1. Overall, I am satisfied with the services I received.	1	2	3	4	5	N/A
As a result of the services I received:
2. I am better at handling daily life.	1	2	3	4	5	N/A
3. I get along better with family members.	1	2	3	4	5	N/A
4. I get along better with friends and other people.	1	2	3	4	5	N/A
5. I am doing better in school and/or work.	1	2	3	4	5	N/A
6. I am better able to cope when things go wrong.	1	2	3	4	5	N/A
7. I am satisfied with my family life right now.	1	2	3	4	5	N/A
Feedback about the services I received:
8. I helped to choose my services.	1	2	3	4	5	N/A
9. I helped to choose my treatment goals.	1	2	3	4	5	N/A
10. The people helping me stuck with me no matter what.	1	2	3	4	5	N/A
11. I felt I had someone to talk to when I was troubled.	1	2	3	4	5	N/A
12. The people helping me listened to what I had to say.	1	2	3	4	5	N/A
13. I was actively involved in my own treatment.	1	2	3	4	5	N/A
14. I received services that were right for me.	1	2	3	4	5	N/A
15. The location of services was convenient.	1	2	3	4	5	N/A
16. Services were available at times that were convenient for me.	1	2	3	4	5	N/A
17. If I need services in the future, I would use these services again.	1	2	3	4	5	N/A
18. I got the help I wanted.	1	2	3	4	5	N/A
19. I got as much help as I needed.	1	2	3	4	5	N/A
20. I, not staff, determined my treatment goals.	1	2	3	4	5	N/A

Please indicate your agreement or 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 N/A, to indicate that this item is “not applicable” to you.	Strongly Agree =1	Agree =2	I am Neutral =3	Disagree =4	Strongly Disagree =5	Not Applicable =N/A
21. Staff treated me with respect.	1	2	3	4	5	N/A
22. Staff understood my family’s cultural traditions.	1	2	3	4	5	N/A
23. Staff respected my family’s religious/spiritual beliefs.	1	2	3	4	5	N/A
24. Staff spoke with me in a way that I understood.	1	2	3	4	5	N/A
25. Staff were sensitive to my cultural/ethnic background.	1	2	3	4	5	N/A
26. I felt discriminated against while trying to get services here.	1	2	3	4	5	N/A

This is the first time we have used this survey so we would like your opinion about it.

1. Were any of the questions hard to understand? Which ones? Why?

2. Were any of the questions unclear? Which ones? Why?

3. Was the questionnaire too long?

4. Did we ask everything that you think is important about mental health services?

5. Are there any questions we should add?

6. Do you have any other comments? (Please use the reverse side if needed)

Thank you for taking the time to answer these questions.