Nta User Satisfaction Survey
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ID no.
TD IST RI BU TE
NTA use only Service no. DAT
Region
Please fill in the questionnaire by putting an X in the boxes if the statements apply to you.
Sex Male
1.
Age
3.
How long have you been attending this service?
1 week or less
1 - 4 weeks
5 - 6 times a week
Daily
Monthly
Less than monthly
More than 3 months
NO
1 - 3 months
1 - 4 weeks
1 - 3 months
1 - 4 weeks
1 - 3 months
More than 3 months
More than 3 months
Do you currently receive the following substitute medication?
Yes
I don't have a keyworker
No
Dose per day
Methadone (prescribed)
mg
Buprenorphine / (SubutexTM )(prescribed)
mg
Do you have a care plan? A care plan shows your treatment needs and explains how they will be met. No
Don't Know
N/A
if no/don't know or n/a, go to q12
How long after starting treatment did you first receive a care plan? 1 - 4 weeks
AF
Within a week 11.
More than 1 year
How long after starting treatment were you allocated a keyworker (who you may know as your counsellor)? This person is your main contact at the drug treatment service and meets with you regularly to discuss your progress.
Yes 10.
2 - 3 times a month
Weekly
TC OP Y– DO
9.
2 - 4 times a week
7 - 12 months
How long did you have to wait, from your comprehensive assessment until your treatment started? For example: regular meetings with a keyworker.
Within a week 8.
4 - 6 months
1 - 4 weeks
Within a week 7.
1 - 3 months
How long did you have to wait, from when you first came to the service until your comprehensive assessment? i.e. the final meeting about your drug use, problems and treatment aims before treatment started.
Within a week 6.
Female
How often do you attend this service?
4.
5.
2.
1 - 3 months
More than 3 months
Never
N/A
When was your care plan last reviewed? A care plan review is a meeting with you and the person or people involved in your care in which you discuss how your care plan is working.
DR
1 - 4 weeks ago
1 - 3 months ago
4 - 12 months ago
Don't know
DRAFT
1 year ago
Never
TD IST RI BU TE
Please indicate your plans regarding the following drugs: mark all that apply with an X
12.
I do not use
I'm happy with my level of use
Heroin Methadone / Buprenorphine (SubutexTM ) Cocaine / crack Amphetamines Cannabis Alcohol Benzodiazepines (e.g. valium)
I would like to reduce my use, but not stop
I would like to stop using this drug completely
Have you requested help in any of the following areas? If yes, have you received help from this service or been referred to another appropriate service? mark all that apply with an X
13.
Type of support
I have requested this type of support from this service
I received support from within this service
Employment / skills training Education Debt management
NO
Housing
I have been referred to another service for support
Legal advice Mental health Benefit advice
TC OP Y– DO
Alcohol advice Stimulant advice Sexual health Dental work
Achieving abstinence
How much do you agree with the following statements? NA means 'not applicable'
14.
Treatment impact
Strongly agree
Your drug use has reduced since starting this treatment
You are less involved in crime since starting this treatment
Your general health has improved since starting this treatment Your mental health has improved since starting this treatment Your housing situation has improved since starting this treatment Your employment situation has improved since starting this treatment
Your relationships have improved since starting this treatment
AF
You do not think this is the right service for you
You have received a lot of help in sorting out your life Your care plan reflects what you need from treatment
DR
You contributed to the development of your care plan This service is good at taking users' views into account This service discourages users from making complaints
DRAFT
Agree
Don't know
Disagree
Strongly disagree
N/A
TD IST RI BU TE
How much do you agree with the following statements? NA means 'not applicable'
15.
How people treat you
Strongly agree
Don't know
Agree
Pharmacy staff treat you with respect Your keyworker treats you with respect Reception staff treat you with respect Doctors treat you with respect Other staff treat you with respect Other users at this service treat you with respect
Strongly disagree
Disagree
N/A
How much do you agree with the following statements? NA means 'not applicable'
16.
Strongly agree
Meeting diverse needs
You have had enough say in decisions about your treatment You only use this service because there is nothing better available Family members / partners do not get enough support
This (treatment) programme is organised and well-run You are satisfied with this treatment programme
Don't know
Disagree
Strongly disagree
N/A
NO
Appointment times for keyworking / meetings at this service are convenient for you This (treatment) programme expects you to learn responsibility and self-discipline
Agree
TC OP Y– DO
The staff here are efficient at doing their job
You get enough personal keyworking at this programme This service location is convenient for you This treatment service meets your needs
Is your service open at any of the following times? mark all that apply with an X
17a.
Mon to Fri after 5pm (at least once a week)
Weekends
Don't know
Does the service open at times convenient for you?
17b. Yes
No
Don't know
Have you ever been asked by this service to give comments on how satisfied or dissatisfied you are with the treatment you receive?
18. Yes
No
Don't know
I understand what is being said to me in this service
19.
Strongly agree
Agree
Don't know
AF
By keyworkers By doctors
By reception staff
DR
In letters
In leaflets
DRAFT
Disagree
Strongly disagree
N/A
TD IST RI BU TE
Which best describes your current employment status?
20.
Regular employment (part time)
Regular employment (full time)
Pupil / student
Unemployed
Do you receive incapacity benefit?
21. Yes
No What is your current housing situation?
22.
No fixed abode
Temporary accommodation
Settled / Permanent accommodation
London Borough
WHITE
ASIAN BLACK CHINESE
White - British
White - Irish
White and Black African
White and Asian
White and Black Caribbean
White and any other background
Asian - Indian
Asian - Pakistani
Asian - Bangladeshi
Any other Asian background
Black - Caribbean
Black - African
TC OP Y– DO
MIXED
NO
Please state your ethnic background
24.
26.
Other
County
Town
Yes
Other
What Town AND County OR which London Borough do you live in?
23.
25.
Economically inactive (house-wife/-husband, pensioner, disabled)
ANY OTHER ETHNIC GROUP
Any other White background
Any other black background
please specify
Are you the parent or carer of children under the age of 16 who live with you? No
Which of the following best describes your sexual orientation?
DR
AF
Straight / heterosexual
Gay / lesbian / homosexual
Bi-sexual
Other
Would rather not say
Thank you very much for completing this questionnaire
DRAFT
TD IST RI BU TE
NTA use only Service no. DAT
Region
Please fill in the questionnaire by putting an X in the boxes if the statements apply to you.
Sex Male
1.
Age
3.
How long have you been attending this service?
1 week or less
1 - 4 weeks
5 - 6 times a week
Daily
Monthly
Less than monthly
More than 3 months
NO
1 - 3 months
1 - 4 weeks
1 - 3 months
1 - 4 weeks
1 - 3 months
More than 3 months
More than 3 months
Do you currently receive the following substitute medication?
Yes
I don't have a keyworker
No
Dose per day
Methadone (prescribed)
mg
Buprenorphine / (SubutexTM )(prescribed)
mg
Do you have a care plan? A care plan shows your treatment needs and explains how they will be met. No
Don't Know
N/A
if no/don't know or n/a, go to q12
How long after starting treatment did you first receive a care plan? 1 - 4 weeks
AF
Within a week 11.
More than 1 year
How long after starting treatment were you allocated a keyworker (who you may know as your counsellor)? This person is your main contact at the drug treatment service and meets with you regularly to discuss your progress.
Yes 10.
2 - 3 times a month
Weekly
TC OP Y– DO
9.
2 - 4 times a week
7 - 12 months
How long did you have to wait, from your comprehensive assessment until your treatment started? For example: regular meetings with a keyworker.
Within a week 8.
4 - 6 months
1 - 4 weeks
Within a week 7.
1 - 3 months
How long did you have to wait, from when you first came to the service until your comprehensive assessment? i.e. the final meeting about your drug use, problems and treatment aims before treatment started.
Within a week 6.
Female
How often do you attend this service?
4.
5.
2.
1 - 3 months
More than 3 months
Never
N/A
When was your care plan last reviewed? A care plan review is a meeting with you and the person or people involved in your care in which you discuss how your care plan is working.
DR
1 - 4 weeks ago
1 - 3 months ago
4 - 12 months ago
Don't know
DRAFT
1 year ago
Never
TD IST RI BU TE
Please indicate your plans regarding the following drugs: mark all that apply with an X
12.
I do not use
I'm happy with my level of use
Heroin Methadone / Buprenorphine (SubutexTM ) Cocaine / crack Amphetamines Cannabis Alcohol Benzodiazepines (e.g. valium)
I would like to reduce my use, but not stop
I would like to stop using this drug completely
Have you requested help in any of the following areas? If yes, have you received help from this service or been referred to another appropriate service? mark all that apply with an X
13.
Type of support
I have requested this type of support from this service
I received support from within this service
Employment / skills training Education Debt management
NO
Housing
I have been referred to another service for support
Legal advice Mental health Benefit advice
TC OP Y– DO
Alcohol advice Stimulant advice Sexual health Dental work
Achieving abstinence
How much do you agree with the following statements? NA means 'not applicable'
14.
Treatment impact
Strongly agree
Your drug use has reduced since starting this treatment
You are less involved in crime since starting this treatment
Your general health has improved since starting this treatment Your mental health has improved since starting this treatment Your housing situation has improved since starting this treatment Your employment situation has improved since starting this treatment
Your relationships have improved since starting this treatment
AF
You do not think this is the right service for you
You have received a lot of help in sorting out your life Your care plan reflects what you need from treatment
DR
You contributed to the development of your care plan This service is good at taking users' views into account This service discourages users from making complaints
DRAFT
Agree
Don't know
Disagree
Strongly disagree
N/A
TD IST RI BU TE
How much do you agree with the following statements? NA means 'not applicable'
15.
How people treat you
Strongly agree
Don't know
Agree
Pharmacy staff treat you with respect Your keyworker treats you with respect Reception staff treat you with respect Doctors treat you with respect Other staff treat you with respect Other users at this service treat you with respect
Strongly disagree
Disagree
N/A
How much do you agree with the following statements? NA means 'not applicable'
16.
Strongly agree
Meeting diverse needs
You have had enough say in decisions about your treatment You only use this service because there is nothing better available Family members / partners do not get enough support
This (treatment) programme is organised and well-run You are satisfied with this treatment programme
Don't know
Disagree
Strongly disagree
N/A
NO
Appointment times for keyworking / meetings at this service are convenient for you This (treatment) programme expects you to learn responsibility and self-discipline
Agree
TC OP Y– DO
The staff here are efficient at doing their job
You get enough personal keyworking at this programme This service location is convenient for you This treatment service meets your needs
Is your service open at any of the following times? mark all that apply with an X
17a.
Mon to Fri after 5pm (at least once a week)
Weekends
Don't know
Does the service open at times convenient for you?
17b. Yes
No
Don't know
Have you ever been asked by this service to give comments on how satisfied or dissatisfied you are with the treatment you receive?
18. Yes
No
Don't know
I understand what is being said to me in this service
19.
Strongly agree
Agree
Don't know
AF
By keyworkers By doctors
By reception staff
DR
In letters
In leaflets
DRAFT
Disagree
Strongly disagree
N/A
TD IST RI BU TE
Which best describes your current employment status?
20.
Regular employment (part time)
Regular employment (full time)
Pupil / student
Unemployed
Do you receive incapacity benefit?
21. Yes
No What is your current housing situation?
22.
No fixed abode
Temporary accommodation
Settled / Permanent accommodation
London Borough
WHITE
ASIAN BLACK CHINESE
White - British
White - Irish
White and Black African
White and Asian
White and Black Caribbean
White and any other background
Asian - Indian
Asian - Pakistani
Asian - Bangladeshi
Any other Asian background
Black - Caribbean
Black - African
TC OP Y– DO
MIXED
NO
Please state your ethnic background
24.
26.
Other
County
Town
Yes
Other
What Town AND County OR which London Borough do you live in?
23.
25.
Economically inactive (house-wife/-husband, pensioner, disabled)
ANY OTHER ETHNIC GROUP
Any other White background
Any other black background
please specify
Are you the parent or carer of children under the age of 16 who live with you? No
Which of the following best describes your sexual orientation?
DR
AF
Straight / heterosexual
Gay / lesbian / homosexual
Bi-sexual
Other
Would rather not say
Thank you very much for completing this questionnaire
DRAFT
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