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NTA use only

Region DAT Service no. ID no.

BU
Please fill in the questionnaire by putting an X in the boxes if the statements apply to you.

1. Age 2. Sex Male Female

RI
3. How long have you been attending this service?

1 week or less 1 - 4 weeks 1 - 3 months 4 - 6 months 7 - 12 months More than 1 year

IST
4. How often do you attend this service?

5 - 6 times 2 - 4 times 2 - 3 times Less than

Daily Weekly Monthly monthly
a week a week a month

5. How long did you have to wait, from when you first came to the service until your

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comprehensive assessment? i.e. the final meeting about your drug use, problems and treatment aims
before treatment started.

Within a week 1 - 4 weeks NO 1 - 3 months More than 3 months

6. How long did you have to wait, from your comprehensive assessment until your treatment
started? For example: regular meetings with a keyworker.

Within a week 1 - 4 weeks 1 - 3 months More than 3 months

7. How long after starting treatment were you allocated a keyworker (who you may know as your
DO

counsellor)? This person is your main contact at the drug treatment service and meets with you
regularly to discuss your progress.

Within a week 1 - 4 weeks 1 - 3 months More than 3 months I don't have a keyworker

8. Do you currently receive the following

Yes No Dose per day
Y–

substitute medication?

Methadone (prescribed) mg
Buprenorphine / (SubutexTM )(prescribed) mg
OP

9. Do you have a care plan? A care plan shows your treatment needs and explains how they will be met.
Yes No Don't Know N/A if no/don't know or n/a, go to q12
TC

10. How long after starting treatment did you first receive a care plan?
Within a week 1 - 4 weeks 1 - 3 months More than 3 months Never N/A
AF

11. 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 - 4 weeks ago 1 - 3 months ago 4 - 12 months ago 1 year ago Never

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Don't know

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

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Heroin
Methadone / Buprenorphine (SubutexTM )
Cocaine / crack
Amphetamines

RI
Cannabis
Alcohol

IST
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 I received support from I have been referred
Type of support

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of support from this service within this service to another service for support
Employment / skills training
Education
Debt management
Housing
NO
Legal advice
Mental health
Benefit advice
Alcohol advice
DO

Stimulant advice
Sexual health
Dental work
Achieving abstinence
Y–

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

14. Treatment impact Strongly Don't Strongly

Agree Disagree N/A
agree know disagree
Your drug use has reduced since starting this treatment
OP

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
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treatment
Your employment situation has improved since starting this
treatment
Your relationships have improved since starting this treatment
You do not think this is the right service for you
AF

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

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

15. How people treat you Strongly

Agree
Don't
Disagree
Strongly
N/A
agree know disagree

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Pharmacy staff treat you with respect
Your keyworker treats you with respect
Reception staff treat you with respect

RI
Doctors treat you with respect
Other staff treat you with respect
Other users at this service treat you with respect

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

16. Meeting diverse needs Strongly Agree Don't Disagree Strongly N/A
agree know disagree

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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
NO
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
DO

You get enough personal keyworking at this programme

This service location is convenient for you
This treatment service meets your needs

17a. Is your service open at any of the following times? mark all that apply with an X
Y–

Mon to Fri after 5pm (at least once a week) Weekends Don't know

17b. Does the service open at times convenient for you?

Yes No Don't know
OP

18. Have you ever been asked by this service to give comments on how satisfied or dissatisfied you
are with the treatment you receive?
Yes No Don't know
TC

19. I understand what is being said to me in this service

Strongly Agree Don't Disagree Strongly N/A

agree know disagree

By keyworkers
AF

By doctors
By reception staff
In letters
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In leaflets

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20. Which best describes your current employment status?

Regular Regular Economically inactive

employment employment Pupil / student Unemployed (house-wife/-husband, Other

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(full time) (part time) pensioner, disabled)

21. Do you receive incapacity benefit?

RI
Yes No

22. What is your current housing situation?

IST
No fixed abode Temporary accommodation Settled / Permanent accommodation Other

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

Town County

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London Borough

24. Please state your ethnic background

NO
WHITE White - British White - Irish Any other White background

White and Black African White and Asian

MIXED
White and Black Caribbean White and any other background
Asian - Indian Asian - Pakistani
DO

ASIAN
Asian - Bangladeshi Any other Asian background

BLACK Black - Caribbean Black - African Any other black background

CHINESE ANY OTHER ETHNIC GROUP please specify

Y–

25. Are you the parent or carer of children under the age of 16 who live with you?

Yes No
OP

26. Which of the following best describes your sexual orientation?

Straight / heterosexual Gay / lesbian / homosexual Bi-sexual Other Would rather not say
TC
AF

Thank you very much for completing this questionnaire

DR

DRAFT