Consumer Survey

Completing this form will enable the Office of Consumer Affairs to prioritize issues for a recipient and family agenda, identify individuals like you who may be a resource to aid in policy and other discussions, and identify information and resource needs that exist.

Fields in bold are required. Place a check in each column next to each issue that you feel is appropriate. You may check more then one box for each issue. Once finished click on the "Submit" button located at the bottom of the page.

First Name

Last Name

Organization

County

Address

City

State

Zip

Telephone Number

E-mail Address

Would you be willing to serve on Boards or Committees?	Yes	No
Do you self-identify as someone who has used mental health services?	Yes	No
Do you self-identify as a family member of someone who has used services?	Yes	No

Clinical Issues

Issues	Would like more information on this issue	Would like to be involved with this issue	Thinks this issue is very important
Advanced Directives
Child Welfare
Civil Commitment
Cultural Competence
Disaster Response
Electroconvulsive Therapy (ECT)
Education
Elder Issues
Employment
Forced Medication
Forensic
Gay/Lesbian/Bi/Transgender/Transexual Issues
Homelessness
Informed Consent
Literacy
Outreach
Participation in Treatment Planning
Restraint and Seclusion
Rural Issues
Stigma
Tobacco Cessation/Reduction
Training Development
Training CME/GRE
Transition Age Youth
Trauma
Treatment Compliance
Veterans Issues
Women's Issues

Entitlements

Issues	Would like more information on this issue	Would like to be involved with this issue	Thinks this issue is very important
Social Security Administration Retirement
Supplemental Security Income (SSI)
Social Security Disability Insurance (SSDI)
Medicaid
Medicare
SSA Plan to Achieve Self-Sufficiency (PASS)
SSA Impariment Related Work Expenses (IRWE)
1619B/1915B Extended Eligibility
Ticket to Work
Section 8 Vouchers
Social Services
Aid to Families with Dependent Children (AFDC)
Energy Assistance
Enterprise Zones
Food Stamps
Temporary Assistance / Special Needs Accounts
Veterans Benefits
Workforce Investment Act

Evidence Based Practices

Issues	Would like more information on this issue	Would like to be involved with this issue	Thinks this issue is very important
Assertive Community Treatment (ACT)
Family Psycho-Education
Integrated Treatment Co-occuring Disorders
Intensive Case Management (ICM)
Medication
Post Traumatic Stress Disorder Treatment
Supported Employment
Self-Help Peer Support Services
Wellness Self-Management
Childrens: EB Prescribing Practices
Childrens: Family Ed. and Support Services
Childrens: Functional Family Therapy
Childrens: Homes Based Crisis Intervention
Childrens: Home & Community Based Services
Childrens: Intensive Case Management (ICM)
Childrens: School Based Mental Health Services
Childrens: PTSD Treatment

Other Issues of Importance

Issues	Would like more information on this issue	Would like to be involved with this issue	Thinks this issue is very important
Child Custody / Parental Rights
Confidentiality
Consumer/Survivor/Ex-Patients as staff
Creative Arts
Cross Disability Issues
Family Issues
Involuntary Treatment
Mental Health Insurance Parity
Parenting Skills
Public Relations
Rights Protection
Self-Help Alternatives
Suicide (Prevention, Grief Counseling, etc.)
Transportation
Voter Registration

Comments or questions about the information on this page can be directed to the Office of Consumer Affairs.

Office of Mental Health

Consumer Survey

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Office of Mental Health

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