Form Modular Survey Modular Survey Modular Survey

Attachment 1 – Modular Survey Instrument

OMB No. 0930-0197

Expiration Date 01/31/2011

Month			Day			Year

ID Number: Date

Form Completed By:  Client  Other

I. Background Information

1. Your age: ____________

2. Gender: Male  Female 

3. Are you Hispanic or Latino?

 No  Yes

4. Which of the following best describes your racial/ethnic background?

Select one or more

 American Indian/Alaska Native

 Asian

 Black or African-American

 Native Hawaiian or Other Pacific Islander

 White

5. What is the primary reason for which you are currently receiving services?

 Mental health  Substance abuse

 Both mental health and substance abuse  Other (Please Specify) _______________________

5. How long have you been receiving services here for your current problem(s)?

 Less than 1 month  1 to 2 months  3 to 5 months

 6 to 11 months  1 to 2 years  More than two years (Specify) ____

­­­­­­­­­­­­­­­­­­­_____________________________________________________________________________________­­­­­­­­­­­­­­­­­­­­­­____________________

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0197. Public reporting burden for this collection of information is estimated to average 10 minutes per respondent per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

7. Have you ever received treatment for this problem or a similar problem anywhere prior to coming here?

 No  Yes

If YES, where – select all that apply

 Hospital, residential treatment

 Outpatient, Day treatment

 Detox

 Crisis intervention / emergency room

 Half-way house

 Peer-support / self-help

 Other ­­­­­­­­­­­­­­­________________________________________

(Please Specify)

7. Did you voluntarily come for services? (Select ALL that apply)

Yes

 No, my treatment was court ordered

 No, I was pressured by family to come for services

 No, I was pressured by friends to come for services

 No, I was pressured by my work/school to come for services

 Other (Please Specify) ________________________

7. Did someone (counselor, therapist, or doctor) from this agency recommend or prescribe medication that was related to your treatment?

 No  Yes

9a. If someone from this agency recommended or prescribed medication, were you told about the side effects of my medication.

 No  Yes

7. When you came for services, were you given information about your rights as a client?

 No  Yes

II. Survey Items

Please read each statement below and think about the services you have received. Fill in the circle that best describes how you feel.

		Disagree	Somewhat Agree	Agree	Strongly Agree	Does Not Apply
1.	When I needed services right away, I was able to see someone as soon as I wanted.					
2.	The people I went to for services spent enough time with me.					
3.	I helped to develop my service/treatment goals.					
4.	The people I went to for services were sensitive to my cultural background (race, religion, language, sexual orientation, etc.).					
5.	I was given information about different services that were available to me.					
6.	I was given enough information to effectively handle my problems.					
As a result of the services (treatment) I have received . . .
7.	I am less bothered by my symptoms.					
8.	I am better able to cope when things go wrong.					
9.	I am better able to accomplish the things I want to do.					
10.	I am not likely to use alcohol and/or other drugs.					
11.	I am doing better at work/school.					
12.	I get along with my teachers/boss.					
13.	There is someone who cares about whether I am doing better.					
14.	I have someone who will help when I have a problem.					
15.	I have people in my life who are a positive influence.					
16.	The people I care about are supportive of my recovery.					
17.	People count on me to help them when they have a problem.					
18.	I have friends who are clean and sober.					
19.	I have someone who will listen to me when I need to talk.					
20.	Using alcohol and/or drugs is a problem for me.					
21.	I need to work on my problems with alcohol and/or drugs.					

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