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Office of Mental Health

New York State Office of Mental Health
Bureau of Inspection and Certification
Draft Family Questionnaire

  1. Are you aware (recipient) is receiving services at the XXX clinic?
  2. Do you know the name of his/her primary therapist at the clinic?
  3. When was the last time you were contacted by anyone from the clinic?
  4. Have you had information and/or observations concerning (recipient's name) that you thought should be communicated to the therapist?
  5. When you speak to clinic staff, how well are you listened to?
  6. Has the clinic therapist indicated how you can assist (recipient's name) met his/her treatment goals?
  7. If you had concern about the services being provided by XXX clinic, do you know who to contact? Have you ever communicated a concern to the clinic? If so, were you satisfied with the clinic's response?
  8. Do you know who to contact at the clinic during times of crisis?
  9. During times of emerging stress or crisis in (recipient's name) condition, does he/she have a safety plan? Do you play any role in the safety plan?

Questionnaire for family of recipients who are children

  1. Do you know the name of your child's primary therapist at the clinic?
  2. Do you feel welcome to actively participate in your child's treatment?
  3. Have you had information and/or observations concerning (recipient's name) that you thought should be communicated to the therapist?
  4. When you speak to clinic staff, how well are you listened to?
  5. Did you and your child have opportunity to participate in the creation of the treatment goals?
  6. Do you feel free to discuss what you hope your child will achieve from treatment and to ask questions about treatment?
  7. If your child is receiving medication treatment, were you fully informed of the risks and benefits of the medication?
  8. Has the clinic therapist indicated how you can assist (recipient's name) meet his/her treatment goals?
  9. Do you feel respected by clinic staff?
  10. If you had concerns about the services being provided by XXX clinic, do you know who to contact? Have you ever communicated a concern to the clinic? If so, were you satisfied with the clinic's response?
  11. Do you know who to contact at the clinic during times of crisis?
  12. During times of emerging stress or crisis in (recipient's name) condition, does he/she have a safety plan? Do you play any role in the safety plan?