INDIVIDUAL PEI PROGRAM DESCRIPTION QUESTIONNAIRE
Version 1.0
Dear Program Director,
Completion of this questionnaire is being requested from all contract and direct service county PEI programs. The purpose of the questionnaire is to help our county to describe the PEI services it funds. Please complete it within two weeks of receipt date and return it to the contact below:
Name of County Contact:
Email Address:
Phone Number:
If you have any questions, not addressed below, please reach out to the County Contact person named above. Thank you for your cooperation.
Questionnaire Instructions1. This questionnaire should be completed by the program management staff person most familiar with the program - either the program director or deputy director. Please include the name and contact information for the person who completes the questionnaire. This information will only be used by the County to clarify answers so that data entry is accurate. Names of individuals will not be associated with their questionnaire responses.
2. The questionnaire is being provided in two formats. One is a version that can be printed out and completed with pen or pencil. It must then be scanned and saved as a .pdf file and emailed as an attachment back to the County. The other version is a fillable form that can be completed online, saved, and emailed back to the County. You can simply click on the response boxes and enter your answers.
3. Please complete every question to the best of your knowledge. Provide your best estimate when precise information to answer the question is not available.
4. Definitions of program categories are provided on page 7 and 8 of the questionnaire.
5. If you are using the pen or pencil version, please print legibly.
6. Please save a copy of your completed questionnaire for your records.
Name of County: Name of Person Completing Questionnaire:
Contact information for person completing this questionnaire:
1. What is the name of the program you are describing? (Please provide full name and any acronym commonly used)
2. Is this program primarily focused on:
(Please check one box)
1 Prevention, or
2 Early intervention, or
3 System change efforts
3. What are the main activities that this program carries out? Many programs do a bit of everything, so try to identify the most important activities for this program, which are directed at the target population for the program. Please refer to Guide below in determining program activities.
(Check all that apply)
1 Outreach and public awareness campaigns -
2 Community strengthening
3 Gatekeeper education and training (including program staff training)
4 Counseling and support
5 Screening and referral
6 System change efforts
7 Clinical services for early intervention
8 Other – what activity?
4. What was the approximate total amount of PEI funding for this program in fiscal year 2012-13? Do not include funding for the program that comes from other sources.
$
5. Please indicate as best you can how the total funding was used across the main activities of this program in fiscal year 2012-13. If an activity is not part of this program, leave the line blank.
ACTIVITIES % OF total program FUNDING
a) Outreach and public awareness campaigns %
b) Community strengthening %
c) Gatekeeper education and training %
d) Counseling and support %
e) Screening and referral %
f) System change efforts %
g) Clinical services for early intervention %
h) Other – what activity? %
100% = TOTAL FUNDING
6. What is the intensity of this program’s main activities taken as a whole?
(Please check one box)
1 Single or light touch activities
2 More intensive activities
3 Both levels
About how many individuals were served by this program in 2012, based on a duplicated and/or unduplicated count?
· Duplicated count – individuals may be counted more than one time if they receive several services within one program within the same reporting period.
· Unduplicated count – individuals are counted only once, no matter how many different services a client is receiving within a program in the same reporting period.
7. Please provide an unduplicated count if possible.
Number of unduplicated individuals
or [ ] Unduplicated count not available
8. Please provide a duplicated count if available.
Number of duplicated individuals
or [ ] Duplicated count not available
9. What are the age groups mainly targeted by this program?
(Check all that apply)
1 Children - Age 0-15
2 TAY - Age 16-25
3 Adults - Age 26-59
4 Seniors - Age 60+
5 No main group(s) – targets all ages equally
10. What are the race/ethnicities mainly targeted by this program?
(Check all that apply)
1 Hispanic/Latino
2 White
3 Black/African American
4 Asian
5 American Indian, Native American, Alaskan Native
6 Native Hawaiian, Pacific Islander
7 Other
8 No main group(s) – targets all equally
11. Are materials and program activities provided in languages other than English?
(Please check one box)
1 Yes – most of them
2 Yes – some of them
3 Materials and activities are in English only
12. What special groups are mainly served by this program?
(Check all that apply)
1 Veterans
2 Military
3 Foster care children/ youth and/or families
4 LBGTQ
5 Undocumented immigrants
6 Low income, Medicaid eligible
7 Underserved
8 Program designed to serve everyone, no targeting of any special group
9 Other
10 NONE OF THESE
13. In the design or operations of this program have there been any specific adaptations to make it more culturally appropriate for the target group(s)?
(Please check one box)
1 Yes
2 No
3 Not applicable
14. We are going to ask about the program and public health goals targeted by this program. Programs may have multiple goals so please try to identify the main goals for the program. What are the main goals for this program? By goals we mean the most immediate intended results of this program.
(Check all that apply)
1 Increased knowledge and more supportive attitudes about mental illness
2 Decreased risk behaviors and/or increased coping skills
3 Decreased distress and/or fewer and less severe symptoms. Could also include preventing crisis situations from escalating
4 Improved individual functioning (could be at home, school, and work) and increased resilience and well-being
5 Improved family functioning
6 Increased help-seeking and utilization of additional assessment and/or treatment services
7 Increased community resiliency, such as improved social climate, reduced stigma and discrimination, and more social supports available in the community
8 Improved systems of care which could include more coordinated and culturally responsive services, increased capacity and access, improved policies and protocols for how individuals move between systems (e.g., primary care to specialty care, or juvenile justice to the school system)
15. Programs may or may not directly target public health goals, but may be intended to contribute to reducing mental health related public health problems. What main public health problem is this program intended to reduce:
(Check all that apply)
1 Suicide
2 School dropout related to mental health
3 Removal of children from the home related to mental health
4 Incarceration related to mental health
5 Homelessness related to mental health
6 Unemployment related to mental health
7 Stigma and discrimination related to mental health
8 Prolonged suffering related to mental health
9 Disparities related to mental health treatment access and/or utilization
16. Are there main program goals that were not covered in these questions?
(Please check one box)
YES -> What goals?
NO, ALL WERE COVERED
Guide to Classifying Program Activities listed above:
Outreach and public awareness campaigns.
Purpose: To increase public knowledge and awareness
Target: General public - individuals not identified on the basis of a specific risk factor.
Examples: Public service announcements; developing and hosting informational websites; creating and distributing pamphlets or other printed material for wide scale distribution; stigma reduction campaigns; hosting health fairs.
Note: Do not include outreach intended to recruit program participants or build community partnerships in this category.
Community strengthening.
Purpose: To increase community resources and resiliency, or to improve social climate and increase social support.
Target: These are universal prevention activities and are not directed towards individuals who have specific risk factors.
Examples: A resource or drop in center (if the primary purpose of the resource program is community strengthening); a school-based anti-bullying program directed at the entire school or community; an exercise program for the elderly; NAMI Family to Family programs and vocational programs; Parent education programs for all parents; school readiness programs that are targeted at all children.
Gatekeeper education and training.
Purpose: To train and educate individuals to recognize someone who is in distress and could benefit from further evaluation or treatment and/or to create a safe and non-stigmatizing environment where someone can self-identify as needing help.
Target: Community leaders, school personnel, emergency workers, and other gatekeepers
Examples: Teacher training programs, training for suicide hotline operators, training for outreach workers and community leaders.
Note: This category includes training of program staff.
Counseling and support.
Purpose: To reduce risk factors and increase copies skills.
Target: At-risk individuals, rather than individuals with a known diagnosis. These programs do
not include universal prevention programs.
Examples: Peer support programs; Resource centers (if the primary purpose is to
provide counseling and support); Suicide hot and warm lines; parent training
programs for children with identified needs or risk factors; violence prevention
programs directed at selected children or youth; Promotoras home visiting programs.
Note: These activities are generally conducted by individuals who are not licensed
mental health clinicians.
Screening and referral.
Purpose: To identify individuals who might benefit from additional assessment and/or counseling.
Target: At risk individuals such as foster youth, new moms, frail elderly.
Examples: School-based screening; suicide hot and warm lines, some Promotoras programs.
System change efforts.
Purpose: To improve system functioning in order to increase appropriate identification of
need and access to services.
Target: Public and private systems.
Examples: Efforts to develop and disseminate culturally appropriate policies and procedures
and culturally competent services, as well as data systems to track individuals. Development of referral networks and efforts to increase and make more efficient collaboration across systems and programs. Efforts to increase access and capacity by reducing inefficiencies could also be included here.
Clinical services for early intervention.
Purpose: To keep mental illnesses from becoming chronic and increasing in severity.
Target: Individuals with either a known or likely diagnosis or symptoms related to a diagnosis.
Examples: First break psychosis programs, PTSD/PTSD symptom treatment programs; primary care
integration programs; school-based trauma treatment; family therapy.
Note: These activities are generally conducted by licensed mental health clinicians.
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