Family Satisfaction Survey

Assisted Outpatient Treatment Evaluation

FAMILY SATISFACTION SURVEY

AOT Program Site: __________________

Client ID#: __________________

Interviewer Name/ID#: ___________________

Interview Date: __ __/__ __/__ __ __ __

Date of Client’s Entry into AOT: __ __ / __ __ / __ __ __ __

Date of Client’s Exit from AOT (if applicable): __ __ / __ __ / __ __ __ __

Date Received by RTI: __ __ / __ __ / __ __

Date Entered: __ __ / __ __ / __ __ Entered by: _____________________ First Name

Date Verified: __ __ / __ __ / __ __ Verified by: _____________________

First Name

INTRODUCTION

[Read to participant. Specific language may be modified by local sites in response to IRB feedback.]

Hello, my name is (YOUR NAME). (CLIENT’S NAME) is participating in an important research project with us, and s/he has given us permission to speak with you. We are talking with family members close to someone receiving assisted outpatient treatment, or AOT, to learn their views on AOT. I’m going to read to you a set of questions exactly as they are worded so that each person is asked the same questions. In some cases, you will be asked to respond in your own words and I will write down your answers. In other cases, you’ll be given a list of answers and asked to choose the one that is best for you. We are interested in your personal opinion and experiences, so please be as accurate as you can in your response. Please take your time to respond and please feel free to ask me for clarification if you are not sure what is wanted. Remember that your answers are confidential. This interview will last about 15 minutes.

DEMOGRAPHICS

A1. Record sex as observed

1 Male

2 Female

9 DK

A2. What is your birth date? __ __/__ __/__ __ __ __ [RF 88/88/8888; DK 99/99/9999]

A3. Which of the following best describes your racial background?

1 Caucasian (White)

2 African American (Black)

3 American Indian

4 Asian

5 Native Hawaiian or Other Pacific Islander

6 Alaska Native

7 Other (specify_____________________________________________)

8 RF

9 DK

A4. Are you Hispanic or Latino(a)?

0 No [SKIP to A5]

1 Yes

8 RF

9 DK

A4a. Are you… [Read list and CIRCLE ALL THAT APPLY]

1 Mexican, Mexican-American, Chicano/a

2 Puerto Rican

3 Cuban

4 Other Hispanic/Latino/a (specify__________________________________________)

8 RF

9 DK

A5. What is your current marital status? Are you…

1 Married

2 Widowed

3 Separated

4 Divorced

5 Never Married

8 RF

9 DK

A6. Are you currently living with your spouse, partner, or with someone else as though you were married? [Interviewer: Sexual relations not necessary for a ‘Yes’ answer]

0 No

1 Yes

8 RF

9 DK

A7. How many children do you have, including your own biological, step, foster, or other children that you take care of regularly?

____ ____ # of kids (RF 98; DK 99)

A7a. How many children do you have under the age of 16 years and how many aged 16 years or older?

____ ____ # of kids under 16 (RF 98; DK 99)

____ ____ # of kids 16 or older (RF 98; DK 99)

A8. What is your relationship to (CLIENT’S NAME)?

1 Parent/stepparent

2 Grandparent

3 Aunt or uncle

4 Brother or sister

5 Spouse or partner

6 Adult child of client

7 Other (specify____________________________________________)

8 RF

9 DK

A9. In the past 6 months, did s/he live with you for more than just a few days?

0 No

1 Yes

8 RF

9. DK

PERCEPTIONS OF AOT

Sometimes people with mental health, alcohol, or drug problems are put on an order for assisted outpatient treatment, or AOT, by a judge. If someone is under AOT, the judge orders them to accept treatment in the community, whether they want it or not.

B1. Here’s a statement. “Assisted outpatient treatment will help people with serious mental health problems stay well.” Please tell me how you feel about this statement. Do you STRONGLY AGREE, AGREE, NEITHER AGREE NOR DISAGREE [or feel mixed], DISAGREE, or DISAGREE SRONGLY?

1 Strongly Agree

2 Agree

3 Neutral/mixed

4 Disagree

5 Strongly Disagree

8 RF

9 DK

B2. When people are under AOT, do you think they are more likely to keep their appointments at the mental health center?

0 No

1 Yes

8 RF

9 DK

B3. When people are under AOT, do you think they are more likely to take their medication?

0 No

1 Yes

8 RF

9 DK

B4. When people are under AOT, do you think they are more likely to stay out of the hospital?

0 No

1 Yes

8 RF

9 DK

INVOLVEMENT IN AND SATISFACTION WITH CIVIL PROCESS

C1. Did you file the petition for (CLIENT’S NAME) to be evaluated for AOT?

0 No

1 Yes

8 RF

9 DK

C2. Did any legal stakeholders (i.e., judge/magistrate, public defender, district attorney) seek your opinion about the case or treatment plan before the AOT docket?

0 No

1 Yes

8 RF

9 DK

C3. Did you feel as though those involved in the petition process cared about what you had to say?

0 No

1 Yes

8 RF

9 DK

C4. How satisfied were you with the petition process overall?

1 Not at all satisfied

2 A little satisfied

3 Satisfied

4 Very satisfied

8 RF

9 DK

[Interviewer: Only ask C5, C6, and C7 if the AOT hearing is open in your jurisdiction.]

C5. Did you attend the court hearing for the judge to decide whether (CLIENT’S NAME) should be put on AOT?

0 No

1 Yes

8 RF

9 DK

C6. Did any legal stakeholders (i.e., judge/magistrate, public defender, district attorney) seek your opinion about the case or treatment plan during the AOT docket?

0 No

1 Yes

8 RF

9 DK

C7. Did you feel as though those involved in the hearing cared about what you had to say?

0 No

1 Yes

8 RF

9 DK

SATISFACTION WITH TREATMENT SERVICES

Next, I would like to ask you about your opinions of mental health services. The first questions are about your contacts with mental health providers concerning (CLIENT’S NAME) since they have been on AOT. [Interviewer: refer back to “Date of Client’s Entry into AOT” on page 1 for the family member to use as reference]

D1. In the time that (CLIENT’S NAME) has been on AOT, how much information have you received from mental health service providers about (CLIENT’S NAME’s) illness?

1 None at all

2 Very little

3 Some

4 A lot

8 RF

9 DK

D2. In the time that (CLIENT’S NAME) has been on AOT, how satisfied have you been with the amount and quality of your contact with mental health professionals pertaining to (CLIENT’S NAME’s) care?

1 Not at all satisfied

2 A little satisfied

3 Satisfied

4 Very satisfied

8 RF

9 DK

D3. In the time that (CLIENT’S NAME) has been on AOT, how satisfied have you been with the mental health systems’ overall responses to your concerns about (CLIENT’S NAME’s)?

1 Not at all

2 Very little

3 Somewhat

4 A lot

8 RF

9 DK

The next questions are about your thoughts about the mental health care (CLIENT’S NAME) has received under AOT. Please answer these questions to the best of your knowledge.

D4. While on AOT, how much help has (CLIENT’S NAME) received from mental health professionals in finding other services, such as housing, legal aid, vocational programs or transportation?

1 None at all

2 Very little

3 Some

4 A lot

8 RF

9 DK

D5. In the time that (CLIENT’S NAME) has been on AOT, how satisfied have you been with the services (CLIENT’S NAME) received?

1 Not at all

2 Very little

3 Somewhat

4 A lot

8 RF

9 DK

Please tell me if you STRONGLY AGREE, AGREE, NEITHER AGREE NOR DISAGREE [or feel mixed], DISAGREE, or DISAGREE SRONGLY with the following statements.

As a direct result of services (CLIENT’S NAME) received while on the AOT order:

	Strongly Agree	Agree	Neutral or Mixed	Disagree	Strongly Disagree	NA	RF	DK
D6. S/he deals more effectively with daily problems.
D7. S/he is better able to control his/her life.
D8. S/he is getting along better with his/her family.
D9. S/he is doing better in school and/or work.
D10. His/her symptoms are not bothering him/her as much.
D11. S/he is better able to stay out of trouble with the law.

CLIENT BEHAVIORS

For the next set of questions, I will ask how often (CLIENT’S NAME) had problems, both with routine tasks and in other areas. During the time that (CLIENT’S NAME) has been on AOT, please tell me if s/he had problems in these areas NEVER, RARELY, OCCASIONALLY, or OFTEN. Ready?

[If NEVER in Part A, skip part B]

	A. Did s/he have problems with:	B. How often did you try to help with these problems?
E1. Maintaining his/her personal hygiene?	0 Never 1 Rarely 2 Occasionally 3 Often 8 RF 9 DK	0 Never 1 Rarely 2 Occasionally 3 Often 8 RF 9 DK
E2. Taking his/her prescribed medications?	0 Never 1 Rarely 2 Occasionally 3 Often 8 RF 9 DK	0 Never 1 Rarely 2 Occasionally 3 Often 8 RF 9 DK
E3. Talk or threats of suicide?	0 Never 1 Rarely 2 Occasionally 3 Often 8 RF 9 DK	0 Never 1 Rarely 2 Occasionally 3 Often 8 RF 9 DK
E4. Excessive use of drugs?	0 Never 1 Rarely 2 Occasionally 3 Often 8 RF 9 DK	0 Never 1 Rarely 2 Occasionally 3 Often 8 RF 9 DK
E5. Excessive use of alcohol?	0 Never 1 Rarely 2 Occasionally 3 Often 8 RF 9 DK	0 Never 1 Rarely 2 Occasionally 3 Often 8 RF 9 DK
E6. Violent or threatening behavior?	0 Never 1 Rarely 2 Occasionally 3 Often 8 RF 9 DK	0 Never 1 Rarely 2 Occasionally 3 Often 8 RF 9 DK

FAMILY WELL-BEING

F1. On the whole, do you feel that, while on AOT, (CLIENT’S NAME) has been:

0 No worry to you

1 A minor worry to you

2 Some worry to you

3 A great worry to you

8 RF

9 DK

F2. Are you currently employed?

1 Employed full time (35+ hrs./week)

2 Employed part time

3 Employed BOTH full time and part time

4 Unemployed

5 Retired

8 RF

9 DK

The following questions refer to the time during which (CLIENT’S NAME) has been on AOT.

F3. If you are employed, how many days did you miss work because you were caring for or providing (CLIENT’S NAME) with assistance? (Use fractions of days if appropriate).

____ days

F4. How many days were you unable to perform your household responsibilities because you were caring for or providing assistance to (CLIENT’S NAME)? (Use fractions of days if appropriate).

____ days

F5. Did you feel burdened by any financial support you provided to (CLIENT’S NAME)? That is, for all the living costs for him/her?

0 Not at all

1 Not much

2 Some

3 A lot

8 RF

9 DK

F6. Are you involved with the National Alliance for the Mentally Ill (NAMI) or any other group for family members of people with mental illness?

0 No

1 Yes, NAMI

2 Yes, other group(s) (specify:_______________________)

8 RF

9 DK

F7. In general, would you say your health is poor, fair, good, or excellent?

1 Poor

2 Fair

3 Good

4 Excellent

8 RF

9 DK

F8. In general, how would you rate your mental health?

1 Poor

2 Fair

3 Good

4 Excellent

8 RF

9 DK

F9. Have you ever been hospitalized for mental health, alcohol, or drug problems?

0 No

1 Yes

8 RF

9 DK

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-NEW. The time required to complete this information collection is estimated to average 15 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