Department of Mental Health System Wide Survey

Demographics

Please start by telling us a little bit about yourself, your back ground, organization and current role. Name is optional.

Question Title

* 1. Name (optional)

Question Title

* 2. What is your primary responsibility at your organization?

Clinician (includes MD, RN, SW, Psychologists, Therapist etc.)

Administrator (even if you have clinical backgroud)

Legal (lawyers, judges etc.)

Legislator

Advocate

Patient Representative

Person receiving mental health services (Patient/Client/Consumer)

Other (please specify)

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* 3. What organization you are affiliated with?

Question Title

* 4. What is your current (primary) work?

Advocacy

Attorney

Crisis Residential staff

Designated Agency Administration

Designated Agency Case Manager

Designated Agency Staff (including Physicians)

DMH Staff

Group Home Staff

Hospital administrator

Hospital Emergency Room Staff (MD, RN, SW, etc.)

Hospital Leadership

Intensive Recovery Residential Staff

Judge

Legislator

Peer run facility staff/leadership

Person receiving mental health services (Patient/Client/Consumer)

Private Practitioner (MD, RN, SW, PhD etc.)

Psychiatric Inpatient Unit Clinician (MD, RN, SW, PhD etc.)

QMHP/Screener

Other (please specify)

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* 5. Years of Experience in your occupation?

0-5 years

6-10 years

11-15 years

16-20 years

21-25 years

26-30 years

> 30 years

Question Title

* 6. Role at your organization

Staff Member

Leadership

Other (please specify)