Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Supported Employment

Kansas Consumer Satisfaction Survey

Mental Health Agency:_________________ County Where You Live:____________

This survey asks for your opinions about the mental health services you receive. Your feedback will be used to help improve the services that are available to you and others. No names are attached to the survey forms, so the information you provide is strictly confidential. Your answers will not be shown to staff at the agency where you receive your services.

Below are listed age, gender, and race/ethnic group categories. Please place a check mark by the categories that fit you. (Note: You may leave this section blank if you prefer not to give this information.)

Age:
____ 16 - 25
____ 26 - 35
____ 36 - 45
____ 46 - 55
____ 56 - 65
____ Over 65

Gender:
____ Female
____ Male

Race or Ethnic group:
____ American Indian or Alaskan Native
____ Asian/Pacific Islander
____ Black/African American
____ Hispanic
____ White
____ Multiple Race/Ethnicity

Some services offered by the Mental Health Center are listed below. Please make a check mark by the services that you have used:

____Case Management
____Partial Hospital
____Educational Services

____Medication Services
____Vocational Services
____Compeer

____Psychosocial Services
____Attendant Care
____Other

INSTRUCTIONS: There are no right or wrong answers. Please answer each question by CIRCLING the number of the choice which matches your opinion at the present time. (Note: The response, “Does Not Apply”, means that you have not used this service or the service is not available where you live.)

Please circle the one choice that best describes your opinion for each statement.	5 Strongly Agree	4 Agree	3 In Between	2 Disagree	1 Strongly Disagree	0 Does Not Apply
1. I have good access to the program (distance, public transportation, parking, etc.)	..5..	..4..	..3..	..2..	..1..	..0..
3. I believe that the staff have my best interest in mind.	..5..	..4..	..3..	..2..	..1..	..0..
4. If I am having a problem with my case manager, the program will make staff changes.	..5..	..4..	..3..	..2..	..1..	..0..
5. I am rarely lonely or bored.	..5..	..4..	..3..	..2..	..1..	..0..
6. The doctor here listens to my concerns and values my opinion.	..5..	..4..	..3..	..2..	..1..	..0..
7. The program’s services and staff help me to stay out of the hospital.	..5..	..4..	..3..	..2..	..1..	..0..
8. As a result of the services I have received here, I am better able to deal with crisis.	..5..	..4..	..3..	..2..	..1..	..0..
9. I am free to make choices about my life without fear of losing the help I get from the program.	..5..	..4..	..3..	..2..	..1..	..0..
10. If I have an emergency at night or on the weekend, I am able to get help from the program	..5..	..4..	..3..	..2..	..1..	..0..
11. Staff follow through on promises they make	..5..	..4..	..3..	..2..	..1..	..0..
12. I can choose where I live.	..5..	..4..	..3..	..2..	..1..	..0..
13. Staff do a good job of telling me about my rights as a consumer.	..5..	..4..	..3..	..2..	..1..	..0..
14. My opinions and ideas are included in my treatment plan.	..5..	..4..	..3..	..2..	..1..	..0..
15. The staff here treat me like an adult, not a child.	..5..	..4..	..3..	..2..	..1..	..0..
17. To the best of my knowledge, staff have kept my personal information confidential.	..5..	..4..	..3..	..2..	..1..	..0..
18. As a result of the services I have received here, I do better with my leisure time.	..5..	..4..	..3..	..2..	..1..	..0..
19. Overall, I am satisfied with the services I receive.	..5..	..4..	..3..	..2..	..1..	..0..
20. If I don’t want the services the staff recommend, they will give me other choices.	..5..	..4..	..3..	..2..	..1..	..0..
21. The staff I work with are competent and knowledgeable.	..5..	..4..	..3..	..2..	..1..	..0..
22. Staff have helped me to maintain a home or apartment in the community.	..5..	..4..	..3..	..2..	..1..	..0..
23. I know who the consumer representative is on the Mental Health Center’s Governing Board.	..5..	..4..	..3..	..2..	..1..	..0..
24. As a result of the services I have received here, I do better in social situations.	..5..	..4..	..3..	..2..	..1..	..0..
25. Staff are willing to see me as often as I feel it is necessary.	..5..	..4..	..3..	..2..	..1..	..0..
26. My doctor tries to find the medications that work best for me.	..5..	..4..	..3..	..2..	..1..	..0..

In the space below, please give us any comments you would like to make about what you like and dislike about the services you receive, and suggestions for how to make things better.
(You may attach additional pages if more space is needed for comments)

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