Shared Decision Making

This survey has only ten questions. It should take approximately 4-5 minutes to complete. We plan to tally the results at the end of October. The report we write will not contain any information about you personally, and will appear on the CQI website.

1. How have you been making decisions about medications with your psychiatrist?

	I make the final decision about which medications I receive.
	I make the final decision about which medications I should take but after seriously considering my psychiatrist's opinion.
	My psychiatrist and I share responsibility for deciding which medications are best for me.
	My psychiatrist makes the final decision about which medications I should take but after seriously considering my opinion.
	My psychiatrist makes all the decisions regarding my medications.

2. How would you prefer to make decisions about medications with your psychiatrist?

	I prefer to make the final decision about which medications I receive.
	I prefer to make the final decision about which medications I should take but after seriously considering my psychiatrist's opinion.
	I prefer that my psychiatrist and I share responsibility for deciding which medications are best for me.
	I prefer that my psychiatrist makes the final decision about which medications I should take but after seriously considering my opinion.
	I prefer that my psychiatrist makes all the decisions regarding my medications.

3. Which statement most accurately describes your stage of recovery?

	I have never heard of, or thought about, recovery from a psychiatric disability.
	I do not believe that I need to recover from any psychiatric problems.
	I have not had the time to really consider recovery.
	I've been thinking about recovery, but I haven't decided to move on it yet.
	I am committed to my recovery, and am making plans to take action very soon.
	I am actively involved in the process of recovery from a psychiatric disability.
	I feel that I am fully recovered; I just have to maintain my gains.

4. How frequently do you see your psychiatrist?

5. Do you receive mental health services that are funded by the government (i.e. Medicaid)?

	Yes
	No
	Not sure
	Not applicable

6. Please select the country in which you live.

7. If you live in the United States, please select your state.

8. If you live in Massachusetts, please select the region of the state in which you live.

9. Please identify your age range.

10. If you are comfortable doing so, please identify your gender.

11. If you have selected "Other" and wish to clarify, please do so here.

12. Is your ethnicity Hispanic or Latino/a?

	No
	Yes

13. Please select your race.

14. If you selected "Other" and wish to clarify, please do so here.

	2 or more times per week
	1 time per week
	every other week
	once a month
	a few times a year
	infrequently