Initial Enrollment Survey (Paper)

OMB Approval Expiration Date

SSI/SSDI Initial Enrollment Survey

Introduction: Thank you for taking time to tell us about your experience working with our Medicaid Eligibility Specialist (and Forensic Peer Mentor, if applicable) to apply for Social Security Income and Social Security Disability Insurance benefits.

Participation is voluntary but very important. The survey takes about 18 minutes to complete. Your responses will be kept private and used only for research purposes. You may skip any question you do not wish to answer. All survey responses will be kept private.

We appreciate your feedback and hope to use your responses to improve services for you and others we work with.

SECTION 1

1. How would you rate your overall quality of life today?

• Delighted

• Pleased

• Mostly Satisfied

• Mixed

• Mostly Dissatisfied

• Unhappy

• Terrible

2. Have you ever received SSI/SSDI benefits before?

• Yes

• No

• I am not sure

3. Before working with the Medicaid Eligibility Specialist, had you ever been told you may qualify for benefits?

• Yes

• No

• Can’t remember

SECTION 2

The next section asks you how you view your mental illness.

Rate how you feel about each statement below.	Strongly Agree	Agree	Neither	Disagree	Strongly Disagree
I believe that I have a mental illness.	○	○	○	○	○
I believe my mental illness has affected my ability to work and/or have a social life.	○	○	○	○	○
I believe medication for my illness helps me control my thoughts and actions.	○	○	○	○	○
I have a hard time communicating and/or organizing my thoughts.	○	○	○	○	○
I am able to recognize when the symptoms of my mental illness are coming back.	○	○	○	○	○
I feel willing to keep taking the medicine for my mental illness.	○	○	○	○	○
I have a plan for finding help if the symptoms of my mental illness return.	○	○	○	○	○
I understand that having a mental illness is nothing to be ashamed of.	○	○	○	○	○
I know what to do for help if I start to feel the symptoms of my mental illness returning.	○	○	○	○	○

SECTION 3

This next section asks you about your experience working with the Medicaid Eligibility Specialist (MES).

13. Describe your overall experience working with the Medicaid Eligibility Specialist (MES).

• Great

• OK

• Poor

Rate how you feel about each statement below.	Strongly Agree	Agree	Neither	Disagree	Strongly Disagree
The MES was knowledgeable about the SSI/SSDI program.	○	○	○	○	○
The MES answered all my questions.	○	○	○	○	○
The MES explained the SSI/SSDI application process to me.	○	○	○	○	○
I felt able to follow the instructions the MES gave me.	○	○	○	○	○
The MES was patient with me.	○	○	○	○	○
The MES kept me up to date on the progress of my application.	○	○	○	○	○
I felt like I could trust the MES.	○	○	○	○	○

21. Are you working with a Forensic Peer Mentor?

• Yes

• No

• I am not sure

SECTION 4

The next section asks about your experience with the Forensic Peer Mentor (FPM).
[IF YES TO 21.]

22. Describe your overall experience working with the Forensic Peer Mentor (FPM).

• Great

• OK

• Poor

Rate how you feel about each statement below.	Strongly Agree	Agree	Neither	Disagree	Strongly Disagree
I feel like the FPM can relate to me.	○	○	○	○	○
I feel comfortable asking the FPM questions.	○	○	○	○	○
The FPM takes time to understand my needs.	○	○	○	○	○
The FPM helps me find useful resources in my community.	○	○	○	○	○
I can easily access the resources the FPM has shown me.	○	○	○	○	○
The FPM genuinely cares about my well-being.	○	○	○	○	○
I plan to continue my relationship with the FPM.	○	○	○	○	○

30. How often does the FPM check in on you?

    1. Daily

    2. Weekly

    3. Every other week

    4. About once per month

    5. I always initiate contact with the FPM