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* 1. Which program are you reviewing?

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* 2. What is your age?

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* 3. What is your gender?

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* 4. Are you Hispanic or Latino?

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* 5. What is your race? (Select all that apply.)

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* 6. How long have you received services from Preferred Behavioral Health Group?

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* 7. Your insurance type: Please select all that apply

Select the number that best represents your response.  Use N/A if a question does not apply to you. 

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* 8. I like the services that I receive here.

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* 9. If I had other choices, I would still get services from this agency.

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* 10. I would recommend this agency to a friend or family member.

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* 11. The location of services was convenient (parking, public transportation, distance, etc.).

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* 12. Staff were willing to see me as often as I felt it was necessary.

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* 13. Staff returned my call in 24 hours.

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* 14. Services were available at times that were good for me.

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* 15. I was able to get all the services I thought I needed.

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* 16. I was able to see a psychiatrist when I wanted to

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* 17. Staff here believe that I can grow, change and recover.

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* 18. I felt comfortable asking questions about my treatment and medication.

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* 19. I felt free to complain.

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* 20. I was given information about my rights.

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* 21. Staff encouraged me to take responsibility for how I live my life.

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* 22. Staff told me what side effects to watch out for.

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* 23. Staff respected my wishes about who is and who is not to be given information about my treatment.

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* 24. I, not staff, decided my treatment goals.

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* 25. Staff were sensitive to my cultural background (race, religion, language, etc.)

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* 26. Staff helped me obtain the information I needed so that I could take charge of managing my illness.

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* 27. I was encouraged to use consumer-run programs (support groups, drop-in centers, crisis phone line, etc.).

As a direct result of services I received:

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* 28. I deal more effectively with daily problems.

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* 29. I am better able to control my life.

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* 30. I am better able to deal with crisis.

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* 31. I am getting along better with my family.

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* 32. I do better in social situations.

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* 33. I do better in school and/or work.

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* 34. My housing situation has improved.

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* 35. My symptoms are not bothering me as much.

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* 36. I do things that are more meaningful to me.

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* 37. I am better able to take care of my needs.

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* 38. I am better able to handle things when they go wrong.

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* 39. I am better able to do things that I want to do.

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* 40. My encounters with the police have been reduced.

For questions 41 – 44 please answer for relationships with persons other than your mental health providers.

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* 41. I am happy with the friendships I have.

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* 42. I have people with whom I can do enjoyable things.

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* 43. I feel I belong in my community.

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* 44. In a crisis, I would have the support I need from family or friends.

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* 45. Comments

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