A Family Member (A
member of your family or a close relative receives mental health
services)
A Friend of a
Consumer
A Concerned Citizen
Are you (or your family member or friend):
Deaf
Hard of Hearing
Hearing
Interpreter
Name (optional):
Address (optional):
City:
State:Zip:
List the following services you (or
your family member or friend) think are the most important services
for the Deaf and Hard of Hearing community. (List #1 for most
important, #15 for the most important)
Service
Rank
Service
Rank
Intake
Assessment
(non-MD)
Crisis Management
Individual
Therapy
Inpatient
Services
Family Therapy
Residential
Services
Case Management
Partial
Hospitalization
MD Assessment
Independent
Living Skills
Case Consultation
Psychological
Testing
School Based
Services
Therapeutic
Foster Care
Intensive In-Home
Services
Supported
Employment
Other:
Which of the following auxiliary
aids do you think should be available "in house" or by written contract to
provide access to deaf and hard of hearing consumers?
Auxiliary
Aid
In House
Contract
Qualified
Interpreters
Note Takers
Written
Transcription Devices(C-CAP
or X-Scribe)
Telecommunication
Devices for the Deaf (TDD/TTY)
Telephone Handset
Amplifiers
Hearing Aid
compatible telephones
Assistive
Listening Systems
Assistive
Listening Devices (individual)
Closed captioned
televisions
Visual Alarms/
other alerting devices
Other
Have you tried to use emergency telephone (hotline) intervention services. Yes
No
If Yes, how did you
access this service?
They
had a TTY/TDD available.
They
had a dedicated TTY/TDD line.
I
used the state dual-party relay service.
I used another method (specify)
Have you attended an
outreach/community information program ?Yes
No
If Yes, how were these
services accessible to Deaf or Hard of Hearing consumers?
They
had interpreters/ALD's for all functions.
I
had to request interpreters/ALD's.
I
had to bring my own
interpreters or ALD's.
I
used another method (specify)
Do you watch videotapes or films
when you receive services?Yes
No
If Yes, how are these services
accessible to Deaf or Hard of Hearing consumers?
They
had interpreters/ALD's for all movies and videotapes.
They
had captioned movies/videotapes and all of their TV's are
closed captioned.
I
had to request an interpreters/ALD's.
I
had to bring my own
interpreters or ALD's.
I
used another method (specify)
