National Psychiatric Advanced Directive Peer Support Assessment

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* 1. Introduction:
We are looking to get a picture of what the peer support workforce knows about Psychiatric Advance Directives (PADs) also known as Mental Health Advance Directives. From this information, we will be able to develop a peer network and plan to inform and educate people about the importance and power of PAD.

Advance Directive Overview
An advance directive outlines a person’s wishes in the event that he or she is incapacitated or unable to express wishes for health care and treatments. Under federal law, any facility receiving Medicare or Medicaid reimbursements is required to use advance directives. Individuals with a physical and mental health condition is covered under this mandate.

Psychiatric/Mental Health Advanced Directive Overview
A Psychiatric/Mental Health Advanced Directive is a legal rights document that allows a person to make preferences regarding mental health treatment known in the event that the person is determined to not to be able to make decisions about their treatment and/or determined incapacitated based on state laws. In effect, the person is giving or withholding consent to treatment in advance of when treatment is needed.

With Psychiatric/Mental Health Advanced Directives people are able to express their preferences on where to receive care and what treatments they are willing to undergo. They are also able to identify an agent or representative who is trusted and legally empowered to make healthcare decisions on their behalf. These decisions may include the use of all or certain medications, preferred facilities, and listings of visitors allowed in facility-based care. Advance directive laws do vary across states. Regardless of state laws PAD can be beneficial and support increased self-determination and quality of services.

A PAD is your voice during a time when things may be out of control. A PAD can protect someone by stating their wishes/preferences when they are unable to do so. Psychiatric Advance Directive is a legal rights document that can help protect you if you are ever in a hospital.

Do you have PAD?

Yes, and it is current

Yes, but it is old

Not sure

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* 2. Do you know if your state has PAD laws?

Yes, I am very familiar with my state laws on PAD

Yes, but I don't know the details

Not sure

No – I don’t know

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* 3. Would you like information on exactly what a PAD is and how it can support you?

Yes

Not sure

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* 4. Are you employed in a position that would call for you to assist others in developing a PAD?

Yes

Not sure

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* 5. Are you trained as a peer specialist or an equivalent position?

Yes

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* 6. Are you doing work supporting the development and/or implementation of PADs?

Yes

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* 7. If yes, please describe the type of PADs work you are currently doing (include the setting and population of focus, for example hospital, criminal justice system, local community mental health system with homeless population)?

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* 8. Demographics

We appreciate you taking the time to complete this anonymous form. Please note that completion of the form and/or each specific question is voluntary. Our organization does not discriminate on the basis of race, ethnicity, sex/gender identity or expression. In order to track the effectiveness of our efforts to be inclusive and ensure we consider the needs of all, please consider the following optional question.

AGE:

15-29

30-34

35-50

51-64

65+

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* 9. Do you identify as someone with mental health challenges/issues? (check all that apply)

Yes, and I'm comfortable with people knowing

Yes, but it's private

Not sure

I do not identify as someone with mental health challenges, but I am interested in learning about PADs to support someone with mental health challenges

I do identify as someone with mental health challenges, and I am interested in learning about PADs to support someone with mental health challenges

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* 10. Please check all that apply to you:

I work for a peer-run organization and/or program

I am a person with lived experience of mental health challenges

I work as a Peer Specialist

Peer Specialist Supervisor

Veteran

I work with youth (ages 16 to 30)

I have been incarcerated

I am homeless or have been homeless

I live in a rural area

I live in an urban area

I am managing a physical health condition

Other (please specify)

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* 11. Check all that apply:

Asian

Black or African American

Latino/a/x

Native American/Indian

Native Alaskan

South Asian

White/Caucasian

Middle Eastern/North African

Native Hawaiians or other Pacific Islanders

Other (please specify)

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* 12. Sexual Identity/Orientation

Undefined

Gay or Lesbian

Bisexual

Questioning

Not sure

Heterosexual or straight

Pansexual

Prefer not to answer

If the above do not adequately reflect you or how you view yourself then please self-describe here:

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* 13. Gender

Transgender

Non-conforming

Non-binary

Female

Male

Prefer not to answer

If the above does not adequately reflect you or how you view yourself then please self-describe here:

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* 14. Any additional information you want to provide about your gender:

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* 15. If you want to be contacted for more information on PADs, provide the following:

Name:

Email:

Phone:

Address:

National Psychiatric Advanced Directive Peer Support Assessment

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* 2. Do you know if your state has PAD laws?

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* 3. Would you like information on exactly what a PAD is and how it can support you?

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* 4. Are you employed in a position that would call for you to assist others in developing a PAD?

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* 5. Are you trained as a peer specialist or an equivalent position?

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* 6. Are you doing work supporting the development and/or implementation of PADs?

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* 7. If yes, please describe the type of PADs work you are currently doing (include the setting and population of focus, for example hospital, criminal justice system, local community mental health system with homeless population)?

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* 9. Do you identify as someone with mental health challenges/issues? (check all that apply)

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* 10. Please check all that apply to you:

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* 11. Check all that apply:

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* 12. Sexual Identity/Orientation

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* 13. Gender

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* 14. Any additional information you want to provide about your gender:

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* 15. If you want to be contacted for more information on PADs, provide the following:

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* 16. Please use this section for any comments, questions or suggestion you mights have regarding PADs: