Name……………………………………………………………………
M / F Age…………….
Where are you
attending?……………………………………………………………………….
This is a questionnaire which
will provide numerical information for us to use in a report for the development of a
Crisis House in Camden. Currently there are only Crisis House places in Islington. The
information you give us will be treated as confidential and will be used in an anonymous
way.
The questionnaire will, we hope, give an indication of the need for
such a facility.
About You
1 - Are you a Camden resident? Yes
No
2 - Have you ever had a psychiatric admission? Yes No
3 - In the last two years, how many hospital
admissions on psychiatric grounds have you had?
1 - 3 3 - 6 6 - 10 More Does not
apply
4 - Do you use a Day Centre? Yes
No
5 - How frequently? 1 day a week,
2 - 3 days a week, 5 days a week, weekends?
6 - Do you use a Day Hospital? Yes
No
7 - How frequently? 1 day a week,
2 - 3 days a week, 5 days a week, weekends?
8 - Do you use a Drop in Service? Yes
No
9 - How frequently? 1 day a week,
2 - 3 days a week, 5 days a week, weekends?
10 - Do you use another service which we haven't
covered? Ie drug or alcohol rehabilitation
………………………………………………………………………………….…………………………….
11- Would you use a Crisis House Service? Yes No
If yes why?
If no why?
12 - What do you think a Crisis House is for?
13 - At what point would you use a Crisis House instead of a hospital?
14 - Would you go to a 24 hour Crisis Drop in Service, if one was
available? Yes No
About the Crisis House Structure
15 - Would you expect to be able to refer yourself to the Crisis House?
Or would you expect to be
referred by a medical professional? Both
16 - How would you expect to be referred to the Crisis House?
By Phone By Drop In By CPN By A&E Other………………………………………
17 - What's the maximum amount of time that
someone should be able to stay?
Up to 1 week Up to 2 weeks Up to
4 weeks
18 - How many beds do you think should be
available in a Crisis House?
6 8 12
19 - Should you be able to come and go as you
please (bearing in mind that you have to be signed in and signed out?
Yes No
20 - Should there be restrictions on visiting hours? Yes No
21 - Should the Crisis House be - all male - all female - mixed
22 - If you had the choice, would you prefer one communal room for everyone or
two
communal rooms - one for women and one for men?
23 - Is being able to have a single bedroom (as
opposed to a shared room) important to you?
Yes No Essential
24 - Should there be an age limit? Yes No Upper age limit…………… Lower age
limit…………
25 - Should you have to pay for Crisis House usage? Yes No
26 - Do you think you should be allowed to smoke in designated areas or would your
prefer it to be non-smoking?
27 - Should the House be alcohol free? Yes
No
28 - What are your most basic expectations of what a Crisis House
should provide?
29 - Would you expect all meals to be provided?
Or one meal
to be provided Or two meals to
be provided
Or for it to be self catering?
30 - Do you think it's essential to have access to a garden at the
Crisis House? Yes No
31 - Is it important that it's in a quiet location? Yes No
About the Staff
32 - Would you expect the staff to be able to
administer medication? Yes No
32 - Would you expect the staff to be medically trained or care
staff or both
33 - Would it be helpful to have someone who's
already used the service to come in and visit? Yes
No
34 - If yes, what would you expect of them?
Short-term befriending, advocacy,
understanding listening, other ……………………
………………………………………………………………………………………………………………………..
35 - Would you expect
one to one counselling or support groups or activities or a key worker
Or house
meetings
other……………………………………………………………..
36 - Would you like access to workshops run by volunteers? Yes No
37 - If yes, what sort of activities or workshops would you like?
38 - Is one member of staff working alone at night enough? Yes No
39 - What kind of support would you expect from the staff in an ideal
world?
40 - Would it be helpful to have a supportive care plan on leaving the
Crisis House? Yes No
41 - For equal opportunities purposes we'd like to ask how you would
sum up your ethnic background in one or two words please.
42 - That's the end of the questionnaire Is there anything else that you'd like to add? |