Form Survey #1 Consumer Survey #1 Consumer Survey #1 Consumer View of Workbook

OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

USER SATISFACTION SURVEY
on
WHAT IS RIGHT FOR ME WORKBOOK
for Mental Health Services Consumers
Thank you for taking the time to answer this survey about your experience with using
the What Is Right For Me Workbook. We are interested in whether the Workbook
helped you think about and make a decision, and whether it helped you talk to mental
health services staff about the decision.
The results from this survey will be used to determine whether the Workbook is useful
for helping people make important decisions and whether it supports shared decisionmaking in mental health services.
Your participation is VOLUNTARY. You may choose to answer this survey or not. If
you choose not to, this will not affect any services you may be receiving.
The information you provide is kept PRIVATE. Your name will not be associated
with this survey. Other information that would let someone identify you will be kept
private. AHP will not share your personal answers with anyone. Reports that explain
the findings of this survey will reflect a collection of information from many participants.
This survey will be destroyed after data collection is completed.
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 15
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 Office, 1 Choke Cherry Road, Room 71044, Rockville, Maryland, 20857.

For Office
Use Only

Date:

Site:

OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

Survey Instructions
You may be asked to skip over some questions in this survey. When this
happens you will either see an arrow with a note that tells you what question to
answer next, like this:
Yes → If Yes, go to #1 on page 1
No
or you will see an instruction like this:
Instructions: Please go to #1 on page 1

Questions
1. Who recommended that you use the
What Is Right For Me Workbook?

3. In your own words, please describe what
your decision was about.

Peer Support Staff
Therapist or Counselor
Doctor, Nurse, or Physician’s Assistant
Case Manager
Family member or friend
Other __________________
No one – I found it

____________________________________
____________________________________
____________________________________
4. How difficult was your decision?
Not at all difficult
Somewhat difficult
Quite difficult
Very difficult

Your Decision
Think about the decision you used the
Workbook for, whether or not you have
made the decision yet, and answer the
following questions.

5. How important to you was your
decision?

2. What was your decision about?

Not at all important
Somewhat important
Quite important
Very important

Mental health services
Medications
Other (for example, housing,
employment, personal relationships)

Please continue on the next page

1

OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

Using the Workbook
6. For each statement below, mark the box that best describes your experience.
Statement
Yes
No
a. The Workbook took too long
b. The Workbook made me more anxious about making a decision
c. The Workbook was helpful
d. I would use the Workbook again when I have another decision to make
e. I would recommend this Workbook to others who have a decision to
make
Not
at all

Statement

As a result of using the Workbook:
f. I felt confident about making my own decision
g. I looked for information to help me make my decision
h. I thought about what is important to me
i. I made the best decision I could in the circumstances
j. I will be a better decision maker in the future
k. I felt less anxious about making a decision
l. I used a step-by-step process to make my decision
m. I identified sources of pressures (for example, other
people or time) that could affect my decision
n. I considered different options
o. I identified pros and cons of my decision
p. I made a plan to implement my decision
q. I determined what I need from other people to carry out
my plan
Please continue on the next page
2

A
little

Some
what

Quite
a bit

Very
much

Does
Not
Apply

OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

10. When you think about the decision you
discussed with this staff person, who did you
want this decision to be made by?

7. Did you use the Workbook to discuss a
decision about mental health services or
treatment issues with a staff person?
No → If No, go to #13 on page 5
Yes

Staff person should make the final
decision without considering my opinion
Staff person should make the final
decision after considering my opinion

Sharing Your Decision
8. What type of staff person did you meet
with?

Staff person and I should share
responsibility for the final decision

Peer Support Staff
Therapist or Counselor
Doctor, Nurse, or Physician’s Assistant
Case Manager
Other____________________
Not sure

I should make the final decision after
considering staff person’s opinion
I should make the final decision
without considering staff person’s opinion
11. When you think about the decision you
discussed with this staff person, who was
this decision actually made by?

9. How long have you been meeting with
this staff person?
This is the first time
Less than two months
More than two months but less than
one year
One year or more

Staff person made the final decision
without considering my opinion
Staff person made the final decision
after considering my opinion
Staff person and I shared
responsibility for the final decision
I made the final decision after
considering the staff person’s opinion
I made the final decision without
considering the staff person’s opinion
Decision has not been made

Please continue on the next page

3

OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

12. For each statement below, mark the box that best describes your experience.
Not
at all

Statement

A
little

As a result of using the Workbook:
a. I felt prepared to talk to the staff person about my mental
health services
b. I was able to explain to the staff person what is
important to me
c. I asked the staff person for information
d. I told the staff person about my previous experiences
with mental health services
e. The staff person and I discussed a number of options
f. I told the staff person how my beliefs affect my decisions
about mental health services
g. I am confident I can talk to this staff person in the future
about changing a decision, if necessary
h. I realized I found it hard to talk about my concerns with
this staff person
i. The staff person and I developed a plan that I can follow
j. I found it easier to communicate with the staff person

As a result of using the Workbook, I felt that the staff person:
k. Gave me information about mental health services
options
l. Respected my right to make a decision about my own
mental health services
m. Understood what is important to me

Instructions: Please go to #17 on page 7

4

Some
what

Quite
a bit

Very
much

Does
Not
Apply

OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

13. Did you use the Workbook to discuss
with a staff person a decision about
something other than mental health
services, such as housing, employment, or a
personal relationship?
No → If No, go to #17 on page 7
Yes

Discussing Your Decision
14. What type of staff person did you meet
with?
Peer Support Staff
Therapist or Counselor
Doctor, Nurse, or Physician’s Assistant
Case Manager
Other____________________
Not sure
15. How long have you been meeting with
this staff person?
This is the first time
Less than two months
More than two months but less than
one year
One year or more

Please continue on the next page

5

OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

16. For each statement below, mark the box that best describes your experience.
Not
at all

Statement

A
little

As a result of using the Workbook:
a. I felt prepared to talk to the staff person about my
decision
b. I was able to explain to the staff person what is
important to me
c. I asked the staff person for information
d. I told the staff person about my previous experiences
with this issue
e. The staff person and I discussed a number of options
f. I told the staff person how my beliefs affect my decisions
g. I am confident I can talk to this staff person in the future
about changing a decision, if necessary
h. I realized I found it hard to talk about my concerns with
this staff person
i. The staff person and I developed a plan that I can follow
j. I found it easier to communicate with the staff person

As a result of using the Workbook, I felt that the staff person:
k. Gave me suggestions about options
l. Supported my right to make a decision about my own life
m. Understood what is important to me

Please continue on the next page

6

Some
what

Quite
a bit

Very
much

Does
Not
Apply

OMB No. 0930-0197
Expiration Date: XX/XX/XXXX

24. How long have you received services from
this agency?

About You
17. What is your gender?

This is the first time
Less than one year
Between one and five years
More than five years

Female
Male
18. How old are you?

25. What information have you seen or
heard about Shared Decision-Making?

__________ years

Presentation
Brochure
Video
Internet
Journal or Newspaper Article
Other_____________________
I have not heard about Shared
Decision-Making

19. Are you of Hispanic or Latino origin?
Yes
No
20. What is your race? Mark all that apply.
American Indian/Alaskan Native
Asian
Black or African-American
Native Hawaiian or other Pacific
Islander
White

26. Is there anything else you think we
should know about your experience using
the Workbook to make a decision or discuss
a decision with staff?
__________________________________

21. How much education did you complete?

__________________________________

Less than High School
High School or GED
Some college
College graduate or more

__________________________________
__________________________________

22. What is your current employment
status?

__________________________________
__________________________________

Employed full-time
Employed part-time
Not employed

You have completed the survey.
Thank you for your participation!

23. How long have you been receiving
mental health services?
This is the first time
Less than one year
Between one and five years
More than five years
7