Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Supported Employment

Quality of Life Self-Assessment

This survey asks you to tell us how things are going for you these days. It should take you about 5 minutes to complete. When finished, please give the survey to your care Coordinator so that you can review the results together.

Please print your name, your Care Coordinator’s name and today’s date below.

Your name (please print): ________________________________________

Your Care Coordinator’s name: ____________________________________

Today’s date: _______________________

In this section, we ask you to rate how things are going in different areas of your life. For each statement below, circle the answer that best matches your experience.

Overall, how would you rate …	(Circle one choice for each statement)
Overall, how would you rate …	0	1	2	3	Should this be on your service plan?
The place where you live (your housing).	Poor	Fair	Good	Excellent	Yes	or	No
The amount of money you have to buy what you need.	Poor	Fair	Good	Excellent	Yes	or	No
Your involvement in work, employment.	Poor	Fair	Good	Excellent	Yes	or	No
Your level of education.	Poor	Fair	Good	Excellent	Yes	or	No
Your access to transportation to get around.	Poor	Fair	Good	Excellent	Yes	or	No
Your social life.	Poor	Fair	Good	Excellent	Yes	or	No
Your participation in community activities (leisure, sports, spiritual, volunteer work).	Poor	Fair	Good	Excellent	Yes	or	No
Your ability to have fun and relax.	Poor	Fair	Good	Excellent	Yes	or	No
Your physical health.	Poor	Fair	Good	Excellent	Yes	or	No
Your level of independence.	Poor	Fair	Good	Excellent	Yes	or	No
Your ability to take care of yourself (staying healthy, eating right, avoiding danger).	Poor	Fair	Good	Excellent	Yes	or	No
Your self-esteem (how you feel about yourself).	Poor	Fair	Good	Excellent	Yes	or	No
The effect of Alcohol & other drugs on your life.	Poor	Fair	Good	Excellent	Yes	or	No
Your mental health symptoms.	Poor	Fair	Good	Excellent	Yes	or	No
Overall, how things are going in your life?	Poor	Fair	Good	Excellent	Yes	or	No
Is there anything else that you want on your service plan?	Poor	Fair	Good	Excellent	Yes	or	No

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