RSA-R Provider Form

O’Connell, Tondora, Kidd, Stayner, Hawkins, and Davidson (2007)

Email

Chapter/State

Point of Data Entry

PA Full Name

Age

Date of Joining The Banyan

How many days taken care of the new scale up homes?

Education Level

Education Level (Other)

Please select below which reflects how accurately the following statements describe the activities, values, policies, and practices of this program.

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree	Don't Know	Not Applicable
Staff make a concerted effort to welcome people in recovery and help them to feel comfortable in this program
This program/agency offers an inviting and dignified physical environment (e.g., the lobby, waiting rooms, etc.).
Staff encourage program participants to have hope and high expectations for their recovery.
Program participants can change their clinician or case manager if they wish.
Program participants can easily access their treatment records if they wish.
Staff do not use threats, bribes, or other forms of pressure to influence the behavior of program participants.
Staff believe in the ability of program participants to recover.
Staff believe that program participants have the ability to manage their own symptoms.
Staff believe that program participants can make their own life choices regarding things such as where to live, when to work, whom to be friends with, etc.
Staff listen to and respect the decisions that program participants make about their treatment and care
Staff regularly ask program participants about their interests and the things they would like to do in the community
Staff encourage program participants to take risks and try new things.
This program offers specific services that fit each participant’s unique culture and life experiences.
Staff offer participants opportunities to discuss their spiritual needs and interests when they wish.
Staff offer participants opportunities to discuss their sexual needs and interests when they wish.
Staff help program participants to develop and plan for life goals beyond managing symptoms or staying stable (e.g., employment, education, physical fitness, connecting with family and friends, hobbies).
Staff routinely assist program participants with getting jobs
Staff actively help program participants to get involved in non-mental health/addiction related activities, such as church groups, adult education, sports, or hobbies.
Staff work hard to help program participants to include people who are important to them in their recovery/treatment planning (such as family, friends, clergy, or an employer).
Staff actively introduce program participants to persons in recovery who can serve as role models or mentors.
Staff actively connect program participants with self-help, peer support, or consumer advocacy groups and programs.
Staff actively help people find ways to give back to their community (i.e., volunteering, community services, neighborhood watch/cleanup).
People in recovery are encouraged to help staff with the development of new groups, programs, or services.
People in recovery are encouraged to be involved in the evaluation of this agency’s programs, services, and service providers.
People in recovery are encouraged to attend agency advisory boards and management meetings.
Staff talk with program participants about what it takes to complete or exit the program.
Progress made towards an individual’s own personal goals is tracked regularly.
The primary role of agency staff is to assist a person with fulfilling his/her own goals and aspirations.
Persons in recovery are involved with facilitating staff trainings and education at this program.
Staff at this program regularly attend trainings on cultural competency.
Staff are knowledgeable about special interest groups and activities in the community.
Agency staff are diverse in terms of culture, ethnicity, lifestyle, and interests.

RSA-R Provider Form

RSA-Provider Form

O’Connell, Tondora, Kidd, Stayner, Hawkins, and Davidson (2007)

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