CJCC Follow-Up Survey

OMB Approval Expiration Date

SSI/SSDI Follow-Up Survey

Introduction: Thank you for taking some time to tell us about the current status of your application for Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) benefits.

Participation is voluntary but very important. The survey takes about 23 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 describe your overall quality of life today?

• Delighted

• Pleased

• Mostly Satisfied

• Mixed

• Mostly Dissatisfied

• Unhappy

• Terrible

2. Did you receive SSI or SSDI benefits?

• Yes – SSI

• Yes – SSDI

• Yes, I received benefits, but I am not sure which one

• No, I was denied benefits

[IF YES]

3. Since receiving benefits, do you feel more financially independent?

• Yes

• Somewhat

• No

4. Can you afford to pay for your basic needs such as food, housing, and utilities?

• Yes

• Somewhat

• No

5. Are you living on your own?

• Yes

• No, I live with family/friends

[IF LIVING WITH FAMILY/FRIENDS]

6. Are you able to contribute to household bills?

• Yes

• No

7. Did you receive Medicaid or Medicare benefits?

• Yes, Medicaid only

• Yes, Medicare only

• Yes, both

• No, I did not receive Medicaid or Medicare

• I am not sure

[IF YES TO MEDICAID, MEDICARE, OR BOTH]

8. Have you used the Medicaid/Medicare benefit in the past 6 months?

• Yes

• No

9. Have you been able to find a doctor you trust?

• Yes

• Somewhat

• No

10. Do you currently live in a group home/assisted living facility using your SSI/SSDI benefits?

• Yes

• No

• I’m not sure.

11. How easy was it for you to find a doctor using your insurance benefits?

• Very easy

• Easy

• Neither easy nor difficult

• Difficult

• Very difficult

12. How easy was it for you to get the medicine you need with your insurance benefits?

• Very easy

• Easy

• Neither easy nor difficult

• Difficult

• Very difficult

13. Do you believe your benefits have been helpful?

• Yes

• Mostly

• Somewhat

• Not very

• Not at all

[IF NO TO #2]

14. Are you appealing the decision to deny benefits?

• Yes

• No

• I have not yet decided

[IF YES]

15. Are you working with the MES who helped you submit your application on the appeal?

• Yes

• No

SECTION 2

This section asks about your experience with the appeals process with the Medicaid Eligibility Specialist (MES).

[IF YES TO #15]

16. Describe your overall experience working with the Medicaid Eligibility Specialist (MES) on the appeal.

• Great

• OK

• Poor

Rate how you feel about each statement below.	Strongly Agree	Agree	Neither	Disagree	Strongly Disagree
The MES is knowledgeable about the appeals process.	○	○	○	○	○
The MES answers all my questions.	○	○	○	○	○
The MES explains the SSI/SSDI appeal process to me.	○	○	○	○	○
I can follow the instructions the MES gives me.	○	○	○	○	○
The MES seems interested in helping me with my appeal.	○	○	○	○	○
The MES is patient with me.	○	○	○	○	○
The MES keeps me up to date on the progress of my appeal.	○	○	○	○	○

SECTION 3

This 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 do not know what to do for help if I start to feel the symptoms of my mental illness returning.	○	○	○	○	○

33. 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 33.]

34. 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 has helped me find useful resources in my community.	○	○	○	○	○
I can easily access the resources the FPM has shown me.	○	○	○	○	○
I feel like the FPM genuinely cares about my wellbeing.	○	○	○	○	○
I plan to continue my relationship with the FPM.	○	○	○	○	○

42. 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