COUNTY OF LOS ANGELES – DEPARTMENT OF MENTAL HEALTH
ADULT SYSTEM OF CARE
Wellness / Client-Run Center
Consumer Feedback Form Guidelines
Introduction
The Department of Mental Health is using a Consumer Feedback Form (CFF) to compile outcome data for clients receiving services at Wellness and Client-Run Centers. The CFF is comprised of 39 items relating to the consumer’s physical well-being, internal experience of Recovery, and social capital or level of integration back into their community.
Procedure
The Consumer Feedback Form is to be administered on a bi-annual basis to all clients receiving services at Wellness or Client-Run Centers, beginning on November 1, 2007. The CFF should be completed by each consumer who comes to the center during the time period. Ideally, the consumer should complete the form, with the assistance of a Peer Advocate or other mental health professional only when needed. For consumers who are seen less frequently, the CFF may be completed by a staff member via a telephone conference with the member, or mailed to the member with a self-addressed stamped envelope.
§ Questions 1 – 35 require the consumer to select the answer that most accurately reflects their level of agreement with the statement.
o Please inform the consumer that some of the questions ask about their personal safety (i.e. question 12) and therefore this survey may not be anonymous if there is concern for the consumer’s safety.
§ Questions 36, 37, and 38 require the consumer to the select all answers that are applicable to their situation. Consumers should also complete blank spaces when appropriate with additional details.
§ Question 39 requires the consumer to select the one answer that best reflects their answer.
§ The last two open ended questions are optional.
Completed forms should be mailed to Urmi N. Patel, PsyD at: Department of Mental Health, Attn. Urmi N. Patel, PsyD – ASOC Administration, 550 S. Vermont Ave, 3rd Floor, Los Angeles CA 90020.
Definitions
ID: For consumers with an open episode, this is their IS number. For consumers without an open episode, the Program must create their own identification number. Reporting on an individual level will be lost if there is no way for the program to track responses back to the consumer.
Provider ID: This is the staff code, or employee number, for the staff that should receive the results of the survey to share with the consumer. This field is intended to be used by providers in the feedback process with consumers and is an optional field.
Survey Setting: This is the description of where the consumer was at the time of completing the CFF.
Site ID: Agency Provider Number
Completed with Staff Assistance: This box must be checked if the CFF was completed with the assistance of a staff member.
Administration Schedule – Fiscal Year 2011-2012:
Survey Administration Period / Surveys Due to DMH8/1/11-1/31/12 / 2/07/12
2/1/12 – 7/31/12 / 8/08/12