MHSIP CONSUMER SURVEY Version 1.2, February 17, 2006

In order to provide the best possible mental health services, we need to know what you think about the services you received during the 

last (specify timer period), the people who provided it, and the results. There is space at the end of the survey to comment on any of your 

answers. Please indicate your agreement/ disagreement with each of the following statements by circling the number that best represents 

your opinion. If the question is about something you have not experienced, circle the number 9 to indicate that this item is “not 

applicable” to you.

Strongly

Agree Agree I am Neutral Disagree

Strongly 

Disagree Not Applicable

1. I like the services that I received here. 1 2 3 4 5 9

2. If I had other choices, I would still get 

services from this agency. 1 2 3 4 5 9 

3. I would recommend this agency to a 

friend or family member. 1 2 3 4 5 9 

4. The location of services was 

convenient (parking, public 

transportation, distance, etc.).

1 2 3 4 5 9 

5. Staff were willing to see me as often 

as I felt it was necessary. 1 2 3 4 5 9 

6. Staff returned my call in 24 hours. 1 2 3 4 5 9

7. Services were available at times that 

were good for me. 1 2 3 4 5 9 

8. I was able to get all the services I 

thought I needed. 1 2 3 4 5 9 

9. I was able to see a psychiatrist when I 

wanted to. 1 2 3 4 5 9 

10. Staff here believe that I can grow, 

change and recover. 1 2 3 4 5 9 

11. I felt comfortable asking questions 

about my treatment and medication. 1 2 3 4 5 9 

12. I felt free to complain. 1 2 3 4 5 9

13. I was given information about my 

rights. 1 2 3 4 5 9 

14. Staff encouraged me to take 

responsibility for how I live my life. 1 2 3 4 5 9 

15. Staff told me what side effects to 

watch out for. 1 2 3 4 5 9 

16. Staff respected my wishes about who 

is and who is not to be given 

information about my treatment.

1 2 3 4 5 9 

17. I, not staff, decided my treatment 

goals. 1 2 3 4 5 9 

18. Staff were sensitive to my cultural 

background (race, religion, language, 

etc.)

1 2 3 4 5 9 

19. Staff helped me obtain the information 

I needed so that I could take charge of 

managing my illness.

1 2 3 4 5 9 

20. I was encouraged to use consumer-run 

programs (support groups, drop-in 

centers, crisis phone line, etc.).

1 2 3 4 5 9 
As a Direct Result of Services I received:

Strongly

Agree

Agree I am Neutral Disagree Strongly 

Disagree

Not Applicable

21. I deal more effectively with daily 

problems. 1 2 3 4 5 9 

22. I am better able to control my life. 1 2 3 4 5 9

23. I am better able to deal with crisis. 1 2 3 4 5 9

24. I am getting along better with my 

family. 1 2 3 4 5 9 

25. I do better in social situations. 1 2 3 4 5 9

26. I do better in school and/or work. 1 2 3 4 5 9

27. My housing situation has improved. 1 2 3 4 5 9

28. My symptoms are not bothering me as 

much. 1 2 3 4 5 9 

29. I do things that are more meaningful 

to me. 1 2 3 4 5 9 

30. I am better able to take care of my 

needs. 1 2 3 4 5 9 

31. I am better able to handle things when 

they go wrong. 1 2 3 4 5 9 

32. I am better able to do things that I 

want to do. 1 2 3 4 5 9 

For questions 33-36 please answer for relationships with persons other than your mental health provider(s)

33. I am happy with the friendships I 

have. 1 2 3 4 5 9 

34. I have people with whom I can do 

enjoyable things. 1 2 3 4 5 9 

35. I feel I belong in my community. 1 2 3 4 5 9

36. In a crisis, I would have the support I 

need from family or friends. 1 2 3 4 5 9 

Please answer the following questions to let us know how you are doing.

37. Are you currently (still) getting mental health services from this Provider?  Yes  No

38. How long have you received mental health services from this Provider? 

  a. Less than a year (less than 12 months) (continue to Question 39)

  b. 1 year or more (at least 12 months) (Skip to Question 42 on page 3) 

 

39. Were you arrested since you began to receive mental 

health services? 

  Yes  No

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

  Yes  No

41. Since you began to receive mental health services, have 

your encounters with the police...

  a. been reduced (for example, I have not been 

 arrested, hassled by police, taken by police to a 

 shelter or crisis program)

  b. stayed the same

  c. increased

  d. not applicable (I had no police encounters this 

 year or last year

42. Were you arrested during the last 12 months?

  Yes  No

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

  Yes  No

44. Over the last year, have your encounters with the 

police...

  a. been reduced (for example, I have not been 

 arrested, hassled by police, taken by police to a

 shelter or crisis program)

  b. stayed the same

  c. increased

  d. not applicable (I had no police encounters this 

 year or last year
Please feel free to use this space to comment on any of your answers. Also, if there are areas which were not covered by this 

questionnaire which you feel should have been, please write them here. Thank you for your time and cooperation in completing 

this questionnaire.

Please provide the following information for statistical purposes.

a. Are you of Spanish/Hispanic/Latino Origin?  Hispanic or Latino  Not Hispanic or Latino

b. What is your Race? (mark one or more races to indicate what you consider yourself to be)

 American Indian or Alaska Native  Asian  Black (African American)

 Native Hawaiian or Other Pacific Islander  White (Caucasian)  Other: Describe 

c. Birth Date: 

d. Gender:  Male  Female