"Rsa-R Person in Recovery Version Survey Template"

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Code:_____
RSA-R
Person in Recovery Version
Please circle the number below which reflects how accurately the following statements describe the activities,
values, policies, and practices of this program.
1
2
3
4
5
Strongly Disagree
Strongly Agree
N/A= Not Applicable
D/K= Don’t Know
1. Staff welcome me and help me feel comfortable in this program.
1
2
3
4
5
N/A
D/K
2. The physical space of this program (e.g., the lobby, waiting rooms, etc.) feels
1
2
3
4
5
N/A
D/K
inviting and dignified.
3. Staff encourage me to have hope and high expectations for myself and my
1
2
3
4
5
N/A
D/K
recovery.
4. I can change my clinician or case manager if I want to.
1
2
3
4
5
N/A
D/K
5. I can easily access my treatment records if I want to.
1
2
3
4
5
N/A
D/K
6. Staff do not use threats, bribes, or other forms of pressure to get me to do what
1
2
3
4
5
N/A
D/K
they want.
7. Staff believe that I can recover.
1
2
3
4
5
N/A
D/K
8. Staff believe that I have the ability to manage my own symptoms.
1
2
3
4
5
N/A
D/K
9. Staff believe that I can make my own life choices regarding things such as
1
2
3
4
5
N/A
D/K
where to live, when to work, whom to be friends with, etc.
10. Staff listen to me and respect my decisions about my treatment and care.
1
2
3
4
5
N/A
D/K
11. Staff regularly ask me about my interests and the things I would like to do in
1
2
3
4
5
N/A
D/K
the community.
12. Staff encourage me to take risks and try new things.
1
2
3
4
5
N/A
D/K
13. This program offers specific services that fit my unique culture and life
1
2
3
4
5
N/A
D/K
experiences.
14. I am given opportunities to discuss my spiritual needs and interests when I
1
2
3
4
5
N/A
D/K
wish.
15. I am given opportunities to discuss my sexual needs and interests when I wish.
1
2
3
4
5
N/A
D/K
16. Staff help me to develop and plan for life goals beyond managing symptoms or
staying stable (e.g., employment, education, physical fitness, connecting with
1
2
3
4
5
N/A
D/K
family and friends, hobbies).
17. Staff help me to find jobs.
1
2
3
4
5
N/A
D/K
18. Staff help me to get involved in non-mental health/addiction related activities,
1
2
3
4
5
N/A
D/K
such as church groups, adult education, sports, or hobbies.
19. Staff help me to include people who are important to me in my
1
2
3
4
5
N/A
D/K
recovery/treatment planning (such as family, friends, clergy, or an employer).
20. Staff introduce me to people in recovery who can serve as role models or
1
2
3
4
5
N/A
D/K
mentors.
21. Staff offer to help me connect with self-help, peer support, or consumer
1
2
3
4
5
N/A
D/K
advocacy groups and programs.
22. Staff help me to find ways to give back to my community, (i.e., volunteering,
1
2
3
4
5
N/A
D/K
community services, neighborhood watch/cleanup).
O’Connell, Tondora, Kidd, Stayner, Hawkins, and Davidson (2007)
Code:_____
RSA-R
Person in Recovery Version
Please circle the number below which reflects how accurately the following statements describe the activities,
values, policies, and practices of this program.
1
2
3
4
5
Strongly Disagree
Strongly Agree
N/A= Not Applicable
D/K= Don’t Know
1. Staff welcome me and help me feel comfortable in this program.
1
2
3
4
5
N/A
D/K
2. The physical space of this program (e.g., the lobby, waiting rooms, etc.) feels
1
2
3
4
5
N/A
D/K
inviting and dignified.
3. Staff encourage me to have hope and high expectations for myself and my
1
2
3
4
5
N/A
D/K
recovery.
4. I can change my clinician or case manager if I want to.
1
2
3
4
5
N/A
D/K
5. I can easily access my treatment records if I want to.
1
2
3
4
5
N/A
D/K
6. Staff do not use threats, bribes, or other forms of pressure to get me to do what
1
2
3
4
5
N/A
D/K
they want.
7. Staff believe that I can recover.
1
2
3
4
5
N/A
D/K
8. Staff believe that I have the ability to manage my own symptoms.
1
2
3
4
5
N/A
D/K
9. Staff believe that I can make my own life choices regarding things such as
1
2
3
4
5
N/A
D/K
where to live, when to work, whom to be friends with, etc.
10. Staff listen to me and respect my decisions about my treatment and care.
1
2
3
4
5
N/A
D/K
11. Staff regularly ask me about my interests and the things I would like to do in
1
2
3
4
5
N/A
D/K
the community.
12. Staff encourage me to take risks and try new things.
1
2
3
4
5
N/A
D/K
13. This program offers specific services that fit my unique culture and life
1
2
3
4
5
N/A
D/K
experiences.
14. I am given opportunities to discuss my spiritual needs and interests when I
1
2
3
4
5
N/A
D/K
wish.
15. I am given opportunities to discuss my sexual needs and interests when I wish.
1
2
3
4
5
N/A
D/K
16. Staff help me to develop and plan for life goals beyond managing symptoms or
staying stable (e.g., employment, education, physical fitness, connecting with
1
2
3
4
5
N/A
D/K
family and friends, hobbies).
17. Staff help me to find jobs.
1
2
3
4
5
N/A
D/K
18. Staff help me to get involved in non-mental health/addiction related activities,
1
2
3
4
5
N/A
D/K
such as church groups, adult education, sports, or hobbies.
19. Staff help me to include people who are important to me in my
1
2
3
4
5
N/A
D/K
recovery/treatment planning (such as family, friends, clergy, or an employer).
20. Staff introduce me to people in recovery who can serve as role models or
1
2
3
4
5
N/A
D/K
mentors.
21. Staff offer to help me connect with self-help, peer support, or consumer
1
2
3
4
5
N/A
D/K
advocacy groups and programs.
22. Staff help me to find ways to give back to my community, (i.e., volunteering,
1
2
3
4
5
N/A
D/K
community services, neighborhood watch/cleanup).
O’Connell, Tondora, Kidd, Stayner, Hawkins, and Davidson (2007)
Code:_____
23. I am encouraged to help staff with the development of new groups, programs,
1
2
3
4
5
N/A
D/K
or services.
24. I am encouraged to be involved in the evaluation of this program’s services
1
2
3
4
5
N/A
D/K
and service providers.
25. I am encouraged to attend agency advisory boards and/or management
1
2
3
4
5
N/A
D/K
meetings if I want.
26. Staff talk with me about what it would take to complete or exit this program.
1
2
3
4
5
N/A
D/K
27. Staff help me keep track of the progress I am making towards my personal
1
2
3
4
5
N/A
D/K
goals.
28. Staff work hard to help me fulfill my personal goals.
1
2
3
4
5
N/A
D/K
29. I am/can be involved with staff trainings and education programs at this
1
2
3
4
5
N/A
D/K
agency.
30. Staff listen, and respond, to my cultural experiences, interests, and concerns.
1
2
3
4
5
N/A
D/K
31. Staff are knowledgeable about special interest groups and activities in the
1
2
3
4
5
N/A
D/K
community.
32. Agency staff are diverse in terms of culture, ethnicity, lifestyle, and interests.
1
2
3
4
5
N/A
D/K
O’Connell, Tondora, Kidd, Stayner, Hawkins, and Davidson (2007)
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