Consumer

ATTACHMENT 3

Consumer Survey of the Delivery of Evidence Based Psychotherapy

Consumer Survey of the Delivery of Evidence Based Psychotherapy

INFORMED CONSENT

Thank you for your interest in participating in the consumer survey for individuals being treated for Post-Traumatic Stress Disorder (PTSD). This project will assist the Assistant Secretary for Planning and Evaluation (ASPE) and the National Institute of Mental Health (NIMH) improve the quality of PTSD treatment. Before you complete the survey, please read the section below that explains your rights as a survey participant.

I understand that:

• I have been invited to take part in a survey about my recent experiences receiving mental health services from a therapist for my PTSD diagnosis.

• My participation in this survey is voluntary, and I will not be penalized if I refuse to participate or decide to stop.

• The purpose of the survey is to improve the quality of care for patients with PTSD.

• There is no cost to me to participate in the survey.

• My survey responses will be kept confidential.

• Confidential means that the data will be kept as private as possible.

• My individual answers will not be released to my therapist, the facility where I received treatment, or any other organization.

• Mathematica may share a summary of responses from all participants with ASPE, NIMH, or other organizations to make the survey better and to improve the quality of care for patients with PTSD.

• My information will only be used for this survey, and my name will not be associated with my answers.

• To send me a $20 gift card as a “thank you” for my participation, Mathematica will need to collect my address after I complete the survey. My address will not be used for any other purposes and will not be shared with any other organization.

• I may change my mind and take back my permission at any time.

If I have any questions or concerns, I can contact Melissa Azur, the project director, at [email protected] or (202) 250-3518 or Kirsten Beronio, the Contract Officer Representative, at [email protected].

Please click “continue” below if you wish to complete is survey.

This survey is designed to understand and improve the quality of care provided to people with PTSD. Your thoughts on your current treatment are very important to us.

Please complete this survey based on the most recent session you had with your therapist. Not all of the below items will occur in every therapy session. Choose “yes” only if the item occurred in the most recent therapy session. Choose “no” if the item did not occur in the most recent therapy session. If you cannot remember if an item did or did not occur, please choose “Don’t Remember”.

You may skip any question you do not feel comfortable answering. You may skip a question by hitting the next button without selecting an answer.

Your responses will be kept confidential and will not be shared with your therapist.

During this session:			Please circle one response:
1.	Did you and your therapist discuss an agenda or plan for your session?		Yes / No / Don’t Remember
2.	Did your therapist talk about or check-in on your expectations of how therapy will go?		Yes / No / Don’t Remember
3.	Did your therapist work with you to set goals you both agreed on?		Yes / No / Don’t Remember
4.	Did your therapist help you become aware of or realize feelings, views or thoughts in your life that have been influenced by your traumatic experience? These might include feelings, views, or thoughts about being safe in the world, the presence of danger, trust, and self-esteem		Yes / No / Don’t Remember
5.	Did your therapist ask you several direct questions to make you think critically about or examine your thoughts, feelings, or beliefs? For example, your therapist might ask: How do you know this? Can you give me an example? What are some other ways of viewing this? What are the pros and cons to your way of thinking about this? How did you come to this conclusion? What evidence do you have to justify this?		Yes / No / Don’t Remember
6.	Did your therapist offer other ways of thinking about your issues (e.g., problem areas or areas you want to work on) related to the trauma? For example: Thought: “I can’t trust anyone.” Thought suggested by therapist: “Some people can’t be trusted, but there are other people who are trustworthy.”		Yes / No / Don’t Remember
7.	Did you and your therapist discuss people, events, or places you now avoid or stay away from because of your traumatic experience? For example, someone in a car accident might avoid driving on the freeway.		Yes / No / Don’t Remember
8.	Did your therapist do any of the following things to help you deal with fear, anxiety or things you now avoid because of your trauma?		Yes / No / Don’t Remember
	a. Ask you to imagine or retell your traumatic experience for longer than 10 minutes		Yes / No / Don’t Remember
	b. Ask you to write about your traumatic experience		Yes / No / Don’t Remember
	c. Ask you questions to make you think critically about or examine your thoughts, feelings, or beliefs related to your fear, anxiety, and avoidance of things (i.e., “How do you know this? Can you give me an example?”)		Yes / No / Don’t Remember
	d. Ask you to do real world experiments like visiting a place related to the traumatic experience for longer than 10 minutes.		Yes / No / Don’t Remember
9.	After you described your traumatic experience, did you and your therapist discuss the details of what happened to you, how it impacted your life, or your emotions about the event?		Yes / No / Don’t Remember
10.	Did your therapist make good use of your session time today?		Yes / No / Don’t Remember
11.	Did your therapist ask for your opinion on how your treatment is going?		Yes / No / Don’t Remember
12.	Did your therapist ask for feedback on how she/he is doing in helping you recover from your PTSD?		Yes / No / Don’t Remember
13.	Did your therapist assign homework or practice assignments (to be completed by the next sessions) to work on your PTSD symptoms or problem areas?		Yes / No / Don’t Remember
14.	Did your therapist make sure you understood how to complete your homework for the next session?		Yes / No / Don’t Remember
15.	If you had problems completing your previously assigned homework, did your therapist work with you to come up with solutions to these problems?		Yes / No / Don’t Remember
16.	Did your therapist review and discuss your homework from the previous session?		Yes / No / Don’t Remember
17.	When reviewing the homework from the previous session, did your therapist encourage or provide you with constructive feedback?		Yes / No / Don’t Remember
For the following questions, please think about the overall course of treatment with this therapist rather than the last session.
18.	My therapist and I have built mutual trust.	Never / Rarely / Occasionally / Sometimes / Often / Very Often / Always
19.	I am confident in my therapist’s ability to help me.	Never / Rarely / Occasionally / Sometimes / Often / Very Often / Always
20.	I believe my therapist likes me as a person.	Never / Rarely / Occasionally / Sometimes / Often / Very Often / Always
21.	a. Has your therapist ever asked you if have had thoughts about committing suicide?		Yes / No / Don’t Remember
	b. During this session, did your therapist ask you if you had thoughts about committing suicide?		Yes / No / Don’t Remember
22.	a. Has your therapist ever asked you to answer questions about your PTSD symptoms? This might include completing a form before or after therapy.		Yes / No / Don’t Remember
	b. During this session, did your therapist ask you about your PTSD symptoms? This might include completing a form or survey before or after therapy.		Yes / No / Don’t Remember
23.	a. Has your therapist ever provided information about PTSD and PTSD symptoms?		Yes / No / Don’t Remember
	b. During this session, did your therapist provide information about PTSD and PTSD symptoms?		Yes / No / Don’t Remember
24.	a. Has your therapist ever provided with specific education on the nature of the traumatic event (i.e., facts about the type of trauma)? For example, this might include education on the nature of sexual assault. Or how sexual assault generally influences your view points and beliefs		Yes / No / Don’t Remember
	b. During this session, did your therapist ever provide you with specific education on the nature of the traumatic event (i.e., facts about the type of trauma)? For example, this might include education on the nature of sexual assault. Or how sexual assault generally influences your view points and beliefs		Yes / No / Don’t Remember
25.	a. Has your therapist ever explained how your particular treatment will work?		Yes / No / Don’t Remember
	b. During this session, did your therapist explain how your particular treatment will work?		Yes / No / Don’t Remember

Thank you for completing this survey!

PLEASE PRESS SUBMIT TO TRANSMIT YOUR RESPONSES

NOTE for OMB purposes: The user will log in with a unique username and password. By logging in, the system will link their unique ID to the survey data. Once the user hits submit, the system will also timestamp the time of completion and link it to the survey data

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-xxxx . The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer