Region

NTA use only Service no. DAT

ID no.

Please fill in the questionnaire by putting an X in the boxes if the statements apply to you. 1. 3. Age 2.

Sex Male

Female

How long have you been attending this service? 1 - 4 weeks 1 - 3 months

1 week or less 4. Daily 5.

4 - 6 months

How often do you attend this service? 5 - 6 times a week 2 - 4 times a week Weekly

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. 1 - 4 weeks 1 - 3 months More than 3 months

Within a week 6.

How long did you have to wait, from your comprehensive assessment until your treatment started? For example: regular meetings with a keyworker. 1 - 4 weeks 1 - 3 months More than 3 months

Within a week 7.

Within a week 8.

TC OP Y– DO

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. 1 - 4 weeks 1 - 3 months More than 3 months No I don't have a keyworker Dose per day mg mg

Do you currently receive the following substitute medication? Methadone (prescribed)

Buprenorphine / (SubutexTM )(prescribed)

9. Yes 10.

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 1 - 3 months More than 3 months
Never N/A

Within a week 11.

DR

1 - 4 weeks ago Don't know

AF

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. 1 - 3 months ago 4 - 12 months ago 1 year ago Never

DRAFT

NO
Yes

TD IST RI BU TE
7 - 12 months More than 1 year 2 - 3 times a month Monthly
Less than monthly

12.

Please indicate your plans regarding the following drugs: mark all that apply with an X I do not use I'm happy with my level of use I would like to reduce my use, but not stop

Heroin Methadone / Buprenorphine (SubutexTM ) Cocaine / crack Amphetamines Cannabis Alcohol Benzodiazepines (e.g. valium)

13.

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 I have requested this type of support from this service I received support from within this service

Type of support Employment / skills training Education Debt management Housing Legal advice Mental health Benefit advice 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

TC OP Y– DO

NO
Strongly agree Agree Don't know Disagree Strongly disagree

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 You do not think this is the right service for you

Your relationships have improved since starting this treatment You have received a lot of help in sorting out your life Your care plan reflects what you need from treatment You contributed to the development of your care plan

DR

This service is good at taking users' views into account This service discourages users from making complaints

AF

DRAFT

TD IST RI BU TE
I would like to stop using this drug completely I have been referred to another service for support N/A

How much do you agree with the following statements? NA means 'not applicable'

15.

How people treat you

Strongly 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

How much do you agree with the following statements? NA means 'not applicable'

16.

Meeting diverse needs

Strongly agree

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 Appointment times for keyworking / meetings at this service are convenient for you This (treatment) programme expects you to learn responsibility and self-discipline This (treatment) programme is organised and well-run You are satisfied with this treatment programme The staff here are efficient at doing their job This service location is convenient for you This treatment service meets your needs You get enough personal keyworking at this programme

17a.

Is your service open at any of the following times? mark all that apply with an X Weekends Don't know

Mon to Fri after 5pm (at least once a week) 17b. Yes 18. Yes 19.

Does the service open at times convenient for you? 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? No Don't know

I understand what is being said to me in this service
Strongly agree Agree Don't know Disagree Strongly disagree N/A

By doctors In letters

By reception staff

DR

In leaflets

AF

By keyworkers

TC OP Y– DO

DRAFT

NO

TD IST RI BU TE
Agree Don't know Disagree Strongly disagree N/A Agree Don't know Disagree Strongly disagree N/A

20.

Which best describes your current employment status? Regular employment (part time) Pupil / student Unemployed

Regular employment (full time) 21. Yes 22.

Do you receive incapacity benefit? No What is your current housing situation? Temporary accommodation

No fixed abode 23. Town London Borough 24.
WHITE MIXED

Settled / Permanent accommodation

What Town AND County OR which London Borough do you live in? County

Please state your ethnic background White - British White and Black African White and Black Caribbean Asian - Indian

White - Irish

NO

White and Asian

White and any other background Asian - Pakistani Any other Asian background Any other black background

ASIAN BLACK CHINESE

25. Yes 26.

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? Gay / lesbian / homosexual Bi-sexual Other Would rather not say

Straight / heterosexual

AF

DR

TC OP Y– DO

Asian - Bangladeshi Black - Caribbean

Black - African
please specify

ANY OTHER ETHNIC GROUP

Thank you very much for completing this questionnaire

DRAFT

TD IST RI BU TE
Economically inactive (house-wife/-husband, pensioner, disabled) Other Other Any other White background