Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Are you currently attending the _________ clinic?
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If so, how often do you attend? Who is your primary therapist?
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Are you receiving other mental health treatment services in addition to the clinic?
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Was the initial clinic appointment provided within a reasonable amount of time?
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Do you feel welcomed when you visit the clinic?
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Do you have the sense that you can be helped at this clinic? Are your needs met?
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Do you feel that the clinic cares about you?
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Do the goals and objectives listed on your treament plan match your needs and desires? Did you set your goals and objectives for your treatment plan?
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Are the staff of the clinic respectful and sensitive to your culture?
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Have you been prescribed any medication by the clinic psychiatrist? Have the benefits and side effects of your medications been discussed?
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Has the clinic helped you to connect to activities outside the clinic such as peer support groups, spiritual suppor, or educational/recreational opportunities?
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Do you believe the clinic staff memebers have made a sufficient effort to explain to your family/significant others how they can support your recovery?
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Do you know the after hours crisis response system used by the clinic?
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Have you ever used the after hours crisis response system?
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Were you satisfied with the crisis response and assistance?
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How could the crisis response system be improved?
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Have you identified family members and/or significant others who can assist you during times of crisis?
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Do you have a safety plan to be used during times of stress and/or emerging crisis?
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Have you ever used the safety plan? If yes, did the plan work well and were adjustments made to the plan following the crisis?