Consumer Survey
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Purpose: This survey is meant to explore the different manifestations of stigma attached to mental illness.

Intended Scope: Mental Health Consumers in the United States of America

Type of Sampling Technique: Convenience Sampling (Voluntary Survey)

Please read the following note before proceeding It is recognized that there is a number of ways that individuals refer to themselves when discussing their status as having a mental illness, such as mental health consumer, mental illness survivor, in treatment, etc. For the purpose the purpose of this survey the word consumer will be used to refer to those with a psychiatric/psychological diagnosis.

In the event that you become uncomfortable with the statements in this survey please feel free to discontinue the survey and seek what help that you deem necessary to maintain your sense of wellbeing.

Note: This is an anonymous study. Information gathered may be published but will not include identifying information.

Gender:  Male Female

Age (years):  

State of residence:  

Town of residence:  

(Optional)Race/Ethnicity  

If other explain:

Level of Education (Choose only the highest level you have obtained):  

I am:  

(Optional) I use the following benefits and/or assistance for my mental health treatment/recovery (check what applies, if applicable):
SSI   SSDI    Unemployment Compensation   Medicaid   Medicare   Private Insurance   Employer Provided Insurance   Other   None   N/A

If other explain:

(Optional) Primary Diagnosis:

If other explain:

(Optional) Additional Diagnoses (Check all that apply): Bipolar Disorder    Depression    General Anxiety Disorder(s)    OCD    ADD    Adult ADD    ADHD    Schizophrenia    Schizoaffective Disorder    PTSD    Substance Abuse/Addiction    Personality Disorder    Other

If other explain:

Please choose your answer to the following statements.


I believe that in general people's opinion of me have been adversely changed when they discovered that I am a consumer.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I believe that people in my community avoid me as a result of them knowing me to be a consumer.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I believe that if I reveal my status as a consumer to a new acquaintance it would hurt the chances of a friendship developing.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I believe that a romantic relationship that I was in was ended once the individual found out that I am a consumer.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I believe that it being known that I am a consumer has prevented the formation of future romantic relationships.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I believe that I have been turned down for a job when a potential employer learns of my status as a consumer.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I believe that I have been "fired", or "let-go" as a result of an employer learning of my status as a consumer.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I have been given less responsibility at my job, career, or occupation since the time that my employer learned of me being a consumer.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I have noticed that there is a negative view of people with mental illness displayed in the mass media.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I feel that society has a negative view of those who are consumers.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I have found that there is not as much of a negative view of mental illness in the mass media than I have been led to believe.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

The following statements about families apply only to first degree (mother, father siblings, spouse (or partner), and children) relatives.

Members of my family have become more supportive since learning that I am a consumer.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

Members of my family have become less available to me since learning that I am a consumer.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

Members of my family actively avoid interacting with me since learning that I am a consumer.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

When (if at all) I am hospitalized for my mental illness my family visits regularly.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

When (if at all) I am hospitalized for my mental illness my family seems to neglect to visit regularly.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

Friends have become more supportive of me since learning that I am a consumer.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

Friends have become less available to me since learning that I am a consumer.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

Friends have actively avoided me since learning that I am a consumer.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

When (if at all) I am hospitalized for my mental illness my friends visit regularly.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

When (if at all) I am hospitalized for my mental illness my friends seem to neglect to visit regularly.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I feel that the learning of my being a consumer has caused my primary care physician to treat me as less capable of making medical decisions when given information about other health concerns.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I feel that I am judged by my mental health treatment team(s) as being less competent than non-consumers when making decisions about my mental health.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I feel that I have been judged adversely by the court system as a result of it being known that I am a consumer.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I believe that I have been treated with more caution by law enforcement officials as a result of them knowing that I am a consumer.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I believe that I have been mistreated by law enforcement personal as a result of them knowing that I am a consumer.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I believe that the legal system has an unrealistic negative view of people who are consumers.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I have less faith in my abilities as an employee as a result of my being a consumer.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I believe that being a consumer has made me less dependable.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I believe that being a consumer has made me a more sympathetic person.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I believe that my being a consumer has resulted in me becoming more creative.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I believe that I am a less productive member of society as a result of me being a consumer.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree

I believe that I am a more productive member of society as a result of me being a consumer.
Absolutely Disagree   Strongly Disagree   Disagree   Neither Agree or Disagree   Agree   Strongly Agree   Absolutely Agree



Please use the available space below to elaborate on your answers or to add in additional comments.



  


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