OMB No. 0930-0197
Expiration Date 01/31/2011
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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
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) _______________________
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 .25 hours 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.
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)
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) ________________________
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 this medication.
No Yes
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.
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Disagree |
Somewhat Agree |
Agree |
Strongly Agree |
Does Not Apply |
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When I needed services right away, I was able to see someone as soon as I wanted. |
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The people I went to for services spent enough time with me. |
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I helped to develop my service/treatment goals. |
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The people I went to for services were sensitive to my cultural background (race, religion, language, sexual orientation, etc.). |
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I was given information about different services that were available to me. |
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I was given enough information to effectively handle my problems. |
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As a result of the services (treatment) I have received . . . |
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I am less bothered by my symptoms. |
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I am better able to cope when things go wrong. |
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I am better able to accomplish the things I want to do. |
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I am not likely to use alcohol and/or other drugs. |
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I am doing better at work/school. |
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I get along with my teachers/boss. |
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There is someone who cares about whether I am doing better. |
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I have someone who will help when I have a problem. |
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I have people in my life who are a positive influence. |
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The people I care about are supportive of my recovery. |
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People count on me to help them when they have a problem. |
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I have friends who are clean and sober. |
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I have someone who will listen to me when I need to talk. |
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Using alcohol and/or drugs is a problem for me. |
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I need to work on my problems with alcohol and/or drugs. |
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OTP-Specific Questions
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Disagree |
Somewhat Agree |
Agree |
Strongly Agree |
Does Not Apply |
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My program helps me take charge of my recovery. |
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My program is fair and flexible. |
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My program helps me lead a healthier lifestyle. |
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My program works with me to meet my dosage needs. |
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My program tells the public about what is good about medications like mine. |
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I am able to speak with medical staff if I need to. |
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My program tells the public about the benefits of treatment like mine. |
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My program has medication hours that are convenient for me. |
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Because I am in treatment, I commit fewer (or no) crimes. |
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My program helps me learn the skills I need to stand up for myself. |
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My program helps me deal with other agencies that impact my life. |
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My program helps me mend relations with family and friends. |
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My program explains my rights and obligations as a client. |
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I feel OK asking staff about program rules. |
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My program helps me be an active member of my community. |
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My program helps me see that I need more than medication to recover. |
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My program stands up for me with outside agencies and others. |
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My program knows how to help me meet my needs. |
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My program helps me find ways to pay for treatment. |
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Program staff works with me to ensure that my treatment goals are met. |
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I feel safe at my treatment program. |
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The place where I go for my treatment is clean and neat. |
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My program values my concerns about my dose. |
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My program helps me get access to medical care when I need it. |
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My program helps me lead a less risky lifestyle. |
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I use alcohol and/or other drugs, but I just want help for my opiate use. |
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My program includes peer leadership as part of my treatment. |
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I am able to speak with program staff about my treatment. |
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| File Type | application/msword |
| File Title | Attachment 9 Modular Survey |
| Author | Angela Screen |
| Last Modified By | SKING |
| File Modified | 2010-01-07 |
| File Created | 2009-12-18 |