1. Gender

2. Age

3. Race

4. Do you have Medicaid insurance?

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

6. I like the services that I received here.

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

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

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

10. Staff returned my call in 24 hours.

11. Services were available at times that were good for me.

12. I was able to get all the services I thought I needed.

13. I was able to see a psychiatrist when I wanted to.

14. Staff here believes that I can grow, change and recover.

15. I felt comfortable asking questions about my treatment and medication.

16. I felt free to complain.

17. I was given information about my rights.

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

19. Staff told me what side effects to watch out for.

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

21. I, not staff, decided my treatment goals.

22. Staff was sensitive to my cultural background (race, religion, language, etc.)

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

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

25. As a Direct Result of Services I received:

I deal more effectively with daily problems.

26. I am better able to control my life.

27. I am better able to deal with crisis.

28. I am getting along better with my family.

29. I do better in social situations.

30. I do better in school and/or work.

31. My housing situation has improved.

32. My symptoms are not bothering me as much.

33. I do things that are more meaningful to me.

34. I am better able to take care of my needs.

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

36. I am better able to do things that I want to do.

37. For following 4 Questions, please answer for relationships with persons other than your mental health provider(s):

I am happy with the friendships I have.

38. I have people with whom I can do enjoyable things.

39. I feel I belong in my community.

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

41. Please answer for relationships with persons other than your mental health provider(s):

Are you currently (still) getting mental health services from this provider?

42. How long have you received mental health services from this provider?

43. Where you arrested since you began to receive mental health services

44. Were you arrested during the 12 months prior to that?

45. Since you began to receive mental health services, have your encounters with the police…

46. Were you arrested during the last 12 months?

47. Were you arrested during the 12 months prior to that?

48. Over the last year, have you encounters with the police…