Adult Services Outcome Tool Template Page 2
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1
2Response Options
5.
Please indicate your level of agreement or disagreement with the
statements by checking the choice that best represents your feelings
or opinion over the past 30 days. (Please answer for relationships
with persons other than your mental health provider(s).)
a. I am happy with the friendships I have.
b. I have people with whom I can do enjoyable things.
c. I feel I belong in my community.
d. In a crisis, I would have the support I need from family or friends.
STOP HERE AND DO NOT COMPLETE QUESTION 6 IF THIS IS AN INITIAL/INTAKE VISIT
Response Options
6.
Please indicate your level of agreement or disagreement with each
sentence selecting the choice that best represents your opinion over
the past 30 days. If the question is about something you have not
experienced, please select “not applicable” in the last column.
a. Staff here believes that I can grow, change and recover.
b. I felt free to voice concern.
c. Staff encouraged me to take responsibility for how I live my life.
d. Staff are sensitive to my cultural background (race, religion, language, etc.)
e. Staff helped me obtain the information I needed so that I could take charge of
managing my problems/issues.
f. I was encouraged to use consumer run programs (support groups, drop-in center,
crisis phone line, etc.)
g. I felt comfortable asking questions about my treatment and medication.
h. I, not staff, decided my treatment goals.
i. I like the services I received here.
j. If I had other choices, I would still get services from this agency.
k. I would recommend this agency to a friend or family member.
l. Services were available at times that were good for me.
m. I was able to get all the services I thought I needed.
n. I am better able to control my life.
o. I am getting along better with my family.
p. I do better in school and/or work.
q. My housing situation has improved.
r. I can deal more effectively with daily problems.
Adult Services Outcome Tool v.5-8-13 Draft
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