Progress Monitoring Survey

CONSENT TO FOLLOW-UP AND CONSENT TO RELEASE

Sundown M Ranch conducts program evaluation and follow-up studies on all our treatment programs. Sundown M Ranch utilizes an “Web” based program evaluation method. We request that you read the information contained in this release and sign and date the form where indicated. The release of information is for Sundown M Ranch (project evaluation). Mark Loes, Director of Operations at Sundown M Ranch, oversees the overall project management. Any questions or comments can be sent to: Sundown M Ranch, PO Box 217, Selah, WA 98942, or 1-800-326-7444.

PURPOSE AND BENEFITS:

The purpose of this study is to determine the accessibility, effectiveness, efficiency, and satisfaction of the treatment that you received from Sundown M Ranch. The information will help us to evaluate treatment results and will help to ensure quality improvement in the future. The information obtained from you will be grouped with information from others and used for evaluating treatment effectiveness and improving treatment quality. You may refuse to answer any questions or withdraw from the study at any time without affecting your treatment or aftercare.

PROCEDURES:

If you consent, your involvement in the study will consist of participating in one survey at enrollment and one at discharge. You will be requested to complete confidential follow-up surveys at 30 days, 60 days, 90 days, 6 months, and 12 months from the time you complete treatment. The confidential follow-up surveys will be conducted by completing the survey that will be emailed to you. The surveys will include questions about your employment; health; wellness; key support relationships; participation in aftercare and self-help activities; alcohol and drug use; and, satisfaction with the services you received at Sundown M Ranch. Your name will not be kept with the data and you will not be identified in any of the research reports. A unique number is connected to the data and no names or identifiable information is used. All information is confidential.

OTHER INFORMATION:

Participation in this study is entirely voluntary. We feel there are no unforeseeable risks to you if you to enter into this program evaluation. If you decide not to take part in the research or decide to drop out at any time, your treatment will not be affected in any way. If you withdraw consent, no further study contact will be made.

THANK YOU FOR YOUR PARTICIPATION

Consent

I have read and agree with the above statement

Please Enter your Email Address, Program and Medical Record Number

Thank you for your taking the time to take this survey

Email*

Program*

Medical Record Number*

Consent that the above Medical Record is valid*

I agree to the privacy policy.

I agree that I am the owner of the above Medical Record Number.

The following questions have to do with your level of satisfaction with the services you received at Sundown M Ranch. Your answers to these questions will help us improve the care we provide Your help is very much appreciated.

How satisfied were you with the following?

Over the last 7 days, how many days have you used alcohol or other drugs

Over the last 7 days, how much were you bothered by cravings or urges to drink alcohol or use drugs?

0-10 scale with 0=Not at all bothered, 10=Very bothered

How confident are you that you will be able to stay in recovery for the next 7 days, or one week?

0-10 scale with 0=Not at all confident, 10=Very confident

How much do you feel understood and supported by your counselor or primary caregiver?

0-10 scale with 0=Not at all, 10=Very

To what extent do you feel that physical pain prevents you from doing what you need to do?

0-10 scale with 0=Not at all, 10=An extreme amount

Over the last 7 days, how much have you been troubled or bothered by psychological or emotional problems?

0-10 scale with 0=Not at all, 10=Extremely

Is Sundown M Ranch meeting your needs?

What can we could do better to meet your needs?

Progress Monitoring Survey

Progress Monitoring Survey

Consent

DISCRETION AND CONFIDENTIALITY

PHONE

ADDRESS