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Office of Mental Health

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

  1. Are you currently attending the XXX clinic?
  2. If so, how often do you attend? Who is your primary therapist?
  3. Are you receiving other mental health treatment/ support services in addition to attending the clinic?
  4. Was the initial clinical appointment provided within a reasonable period of time?
  5. Do you feel welcomed when you visit the clinic?
  6. Do you have the sense that you can be helped at this clinic? Are your needs met?
  7. Do you feel that the clinic cares about you?
  8. Do the goals and objectives listed on your treatment plan match your needs and desires? Did you set your goals and objectives for your treatment plan?
  9. Are staff of the clinic respectful and sensitive to you culture?
  10. Have you been prescribed any medication by the clinic psychiatrist? Have the benefits and side effects of the medication(s) been discussed?
  11. Has the clinic helped you to connect to activities outside the clinic such as peer support groups, spiritual support, education/recreational opportunities?
  12. Do you believe the clinic staff members have made a sufficient effort to explain to your family/ significant others, how they can support your efforts toward recovery?
  13. Do you know the after hours crisis response system used by the clinic?
  14. Have you ever used the after hours crisis response system?
  15. Were you satisfied with the crisis response and assistance?
  16. How could the crisis response system be improved?
  17. Have you identified family members and/or significant others who can assist you during times of crisis?
  18. Do you have a safety plan to be used during times of stress and/or emerging crisis? Have you ever used the safety plan? If yes, did the plan work well and were adjustments made to the plan following the crisis?
  19. On a scale of 1-10, how much do you feel the clinic services promote hope and recovery?