Clubhouse Profile Questionnaire (CPQ) - 2009 - iccd.org · Clubhouse Profile Questionnaire (CPQ) - 2009. ... Vocational Rehab Agency ... Clubhouse Profile Questionnaire 2009 7 Please

Clubhouse Profile Questionnaire (CPQ) - 2009

This document replaces earlier versions of the Clubhouse Profile and the ICCD Survey. The information collected provides information about clubhouse performance and characteristics in a variety of areas. It also

provides an understanding of similarities and differences among clubhouses internationally. .

Program for Clubhouse Research Center for Mental Health Services Research University of Massachusetts Medical School

55 Lake Avenue North Worcester, MA 01655

USA

1

International Center for Clubhouse Development Clubhouse Profile Questionnaire - 2009

(Please fill out both boxes) Prior Certification Visit dates (use most recent): _________________ Prior Certification team (use most recent): ______________________

Clubhouse Profile Questionnaire 2009 2

Today’s Date: _______________ Certification Site Visit Date: ____________ Certification Team: Name: _____________________________ Clubhouse: _________________________ Name: _____________________________ Clubhouse: _________________________

Most Recent Training Dates: From: _______To: _______ Clubhouse: __________________________ Colleagues: Name: ______________________________ Name: ______________________________ Name: ______________________________ 3rd Week Visitor: _____________________

Clubhouse Name: ________________________________________ Date Clubhouse Opened: ______________ Parent Agency Name: ________________________________________ (month/year) Clubhouse Address: ________________________________________ Date Club Joined ICCD: ______________ ________________________________________ (month/year) Phone Number: ________________________________________ Fax Number: _______________________ E-mail Address: ________________________________________ Web Page Address: ________________________________________ Clubhouse Director’s Name: _______________________________ Director’s Home Phone: _____________________ Other Clubhouse Contact Name: ____________________________ Contact ‘s Phone: __________________________

If you are uncertain about the precise number in a certain category, and do not have any records that might assist you in answering more precisely, please make an educated guess. Responses to the questions about budgets and staffing should be based on your most recent Fiscal Year, which is the most recent 12-month period that you use for financial reporting purposes. In addition, some questions relate to either clubhouses within the United States, or Clubhouses outside of the United States. Please answer those questions that relate to your clubhouse based on your geographic location. Please use an additional sheet of paper if you need additional space.

Clubhouse Organization and Characteristics

Origin: How did your Clubhouse start? (Choose One) ______New program started as a clubhouse ______Other community mental health program ______Hospital program ______Day treatment program ______Rehabilitation facility ______Government agency ______Social program ______Other (please specify) _______________________ Location: ______ Separate building ______ Within parent organization ______ Shared building with other organizations Area Population: What is the population of the area served by the clubhouse? ______ Under 10,000 ______ 10.000 to 25,000 ______ 25,000 to 100,000 ______ 100,000 to 250,000 ______ 250,000 to 500,000 ______ 500,000 to 1,000,000 ______ Over 1,000,000 Unemployment Rate: What is the current unemployment rate in the region you serve? __________%


Clubhouse Budget: What is the clubhouse total annual operating budget NOT including member housing: _____________? ICCD Training Bases: Please do not include training budget What is the clubhouse total annual operating budget including member housing and/or training? ___________ If not sure, estimate: Include staff salaries, building expenses, Clubhouse-based housing, training base budget etc. Do not include the budgets of any satellite programs or services sponsored by the Clubhouse that are not integral to the clubhouse (for example, PACT teams, housing case management teams, respite care facility) Direct costs ______________ Direct costs are clearly and easily attributable to a specific program such as salaries and fringe benefits Indirect costs _____________

Indirect, or shared, costs may include rent, telephone, postage, printing and other expenses which benefit all programs and functions of an organization (Overhead or general and administrative expenses).

*The sum of Direct and Indirect costs should equal the total annual operating budget including housing and/or training. Which sources provide funding towards your clubhouses’ total annual operating budget? Funding from Governmental Sources State or Provincial Mental Health ________% Social Services ________% Vocational Rehab Agency ________% Labor Department ________% County/Borough Government ________% Local/Municipal Government ________% National Grants ________% Public Insurance Programs (such as Medicaid) ________% Other _______________________ ________%

Funding from Private Sources Private Insurance ________% Foundations/Grants ________% Donations and other Private Sources Income generating activities (i.e. Thrift Shop, Food sales, Rents, etc.) ________% Other: ___________________________ ________% TOTAL 100%

Managed Care: (US Clubhouses Only) Is your clubhouse part of a Managed Care system? Yes_____ No_____ Type of Managed Care system: _____ State Government Operated _____ Private Not-For-Profit Company _____ Private For-Profit Company _____ Provider Network _____ Other:________________________________________ Does your clubhouse receive Medicaid funding? Yes_____ No_____ If Yes, describe the activities and services that are Medicaid-funded?


MEMBERSHIP Intake/New Member Orientation Process: What are the eligibility requirements for membership? What percentage of people who participate in orientation become members? _________ Referrals/New Members: Who refers members to your clubhouse?

______% State/County psychiatric hospital ______% City psychiatric hospital ______% Community mental health center ______% Other mental health facilities ______% General hospital ______% Private psychiatrist/therapist ______% Family member/relative ______% Self referral ______% Other members ______% Other (please specify) _________________________________________

Number of individuals referred to the clubhouse during the most recent fiscal year including self-referrals. ___________ No person should be counted more than once. New Members: Number of referrals in the most recent fiscal year that have become members.________ Are people with other diagnoses in addition to a psychiatric diagnosis eligible for membership? ______ If yes, What percent have these diagnoses?

______% Developmentally disabled ______% Traumatic or acquired brain injury ______% Substance abuse ______% Other (please specify) ______________________________

Current Membership: ______ Total membership (Unduplicated count of total members since opening of clubhouse) ______ Total active members – month (Unduplicated count of members with at least one face-to-face contact

with clubhouse staff during the most recent 30-day period. This includes members having contact through Work-ordered Day, social programs, within the community, or employment contact with staff. No person should be counted more than once.)

______ Total active members 90 days (Unduplicated count of members with at least one face-to-face contact with clubhouse staff during the most recent 3-month period. This includes members having contact through Work-ordered Day, social programs, within the community, or employment contact with staff. No person should be counted more than once.)

______ Average daily attendance* (Unduplicated number of members signing in at the clubhouse per day)* ______ Average work ordered day program attendance (Unduplicated number of members signing in during the

clubhouse work ordered day hours) ______ Outreach (Unduplicated number of members receiving face-to-face clubhouse services in the community) _____ Evening/weekend (Number of members participating in any evening or weekend program during the most

recent 3-month period. No person should be counted more than once.) *To calculate Average Daily Attendance: (1) For each weekday in a month (excluding holidays), count how many members attended the clubhouse – includes Work-Ordered day and social program attendance (Count members working a TE positions, but not members working in SE or IE positions unless they also attended the clubhouse; Count each person only once each day even if they returned to the clubhouse several times; (2) Add all daily totals for 1 month; (3) Divide sum by number of weekdays during that month (excluding holidays).


MEMBER CHARACTERISTICS US CLUBHOUSES ONLY: Please estimate the number of active members in each racial category (Sum of men and women column totals should equal Total 90 –Day Active Membership, page 4)

Racial Group Men Women White/Caucasian Hispanic Black/African-AmericanAmerican Indian/Alaska NativeAsian Native Hawaiian or Other Pacific Islander Unknown Totals:

NON-US Clubhouses only: Please list the primary ethnicities of your active members (List from majority to minority)

1. ___________________________________ percentage of membership? ________%




Please estimate the number of active members in each age category. (Total should equal amount entered for Active (90 days) on Pg 4.) Less than 20 Years ___________ 31 to 40 Years _______________ 61 to 70 Years ________________ 20 to 25 Years ______________ 41 to 50 Years _______________ Over 70 Years ________________ 26 to 30 Years ______________ 51 to 60 Years _______________ Unknown ____________________ Do you record the diagnoses of your members? _____ Yes _____ No If yes, Please estimate the number of active members in each diagnostic category.

Diagnosis Number of Active Members (90 days) Schizophrenia, schizoaffective disorders

Bipolar Disorder

Major Depression

Other Diagnoses (1): ____________________

Other Diagnoses (2): ____________________

Unknown


STAFF CHARACTERISTICS Please tell us about the composition of the clubhouse staff

______ Total number of full-time staff (FTE’s) ______ Total number of part-time staff ______ How many of the full-time and part-time staff are unit based? ______ Total numbers of volunteers and/or students

Proportion of current staff identifying themselves as current or former consumers of mental health services ________% For several of the following items, we ask questions about staff in three categories:

Administrators are clubhouse executive directors, directors, or program directors.

Generalist program staff have general responsibilities within the clubhouse, generally including member involvement and some responsibility for employment.

Resource Staff have job descriptions that do not include working with members in the Work-ordered Day (WOD) and/or the provision of community support services as a primary responsibility (for example, janitors, accountants, secretaries, or researchers).

Educational credentials of full-time staff now employed by the clubhouse (Enter the number of staff in each category): (Each staff should be counted once. Use each staff person’s highest level of education. The total should equal the number of FTE’s from above).

Credential Administrators Resource Staff

Generalist Program Staff

Primary school (less than high school)

Secondary school (GED or high school diploma)

Some college or university

Undergraduate degree in Human Services (B.A., B.S.)

Undergraduate Non-Human Services degree (B.A., B.S.)

Some graduate coursework

Masters level (M.A./M.S./M.S.W.) Human Services degree

Masters level (M.A./M.S./M.Ed.) Non-human Services degree

Advanced graduate degree (Ph.D., M.D., D.S.W., etc)

How long have your full-time staff been employed at your clubhouse? Please indicate the number of staff (currently employed) in each category.

Length of Employment Administrators Resource Staff


Less than 1 year

1 to 2 years

3 to 4 years

5 to 10 years

More than 10 years

Number of positions currently open/unfilled


Please list the number of full-time staff employed in each salary category (Each staff should be counted once. The total should equal the number of FTE’s from the previous page).

Salary Range (in US dollars)

Administrators

Resource Staff


Up to $15,000.

$15,001 to $20,000.

$20,001 to $25,000.

$25,001 to $30,000.

$30,001 to $35,000.

$35,001 to $40,000.

$40,001 to $45,000.

$45,001 to $50,000.

$50,001 to $60,000.

$60,001 to $75,000.

$75,001 to $100,000.

Over $100,000

SPACE How much interior space does your clubhouse occupy? _____ square feet or ______ square meters Is all the space in your clubhouse accessible to members? Yes_____ No_____ (i.e., members permitted in all club space).

If no, please describe areas that are inaccessible: _______________________________________________________ How much of the space in your clubhouse is physically accessible to persons with mobility impairments? All _____ More than 50% _____ Less than 50% _____ None_______

Work-Ordered Day

This section asks about the Work-ordered Day (WOD). By this, we mean hours during the typical business workweek (for ex. Monday-Friday, 9AM-5PM or 8AM-4PM, excluding holidays) set aside exclusively for Clubhouse work, which is designed to strengthen members’ self-worth, purpose and confidence. Members work side-by-side with staff on tasks essential to the well-being and survival of the Clubhouse. The schedule and atmosphere of the WOD resemble a normal business environment, but members are not required to work. What are the daily hours of your Work-ordered Day? ____________ to ____________ How many distinct work units do you have? ____ By distinct work unit, we mean a unit that has a title, a unit leader, and a specific location in the clubhouse. What types of clubhouse work do members carry out in any of these units? ( All that apply) Clerical/Office ____ Research ____ Supported Education ____ Food Prep/Serving ____ Accounting ____ Employment ____ Maintenance/Cleaning ____ Telephone Switchboard ____ Supported Housing ____ Administration ____ Attendance Records ____ Outreach: ____ Enrollment/Orientation ____ Thrift Store ____ Other: ________________________


Please describe each unit in your clubhouse:

Unit Name Average

Daily Hours

Average Daily

Attendance

Active Membership

in Unit

Number of Staff in Unit

Number of Unit

Meetings per week

Unit Tasks

Please indicate how frequently the following meetings occur in your clubhouse ( each appropriate box)

Meeting Type At least Daily

At least Weekly

At least Biweekly

At least Monthly

Less than Monthly Not at All

Informational Community/House Policy/Decision Making

Employment Educational

Substance Abuse/Prevention Parenting Supports

Healthy Lifestyles (Wellness) Medication-Education

Social Board of Directors

Advisory Board Other:_______________________ Other:_______________________ Other:_______________________


Employment

In this section, please use the following definitions of employment types to complete the questions and tables Transitional Employment (TE): Clubhouse-owned individually held job offering: (1) Employee selection by clubhouse, (2) job training by clubhouse members or staff, (3) absence coverage, (4) a time-limited opportunity, usually 6-9 months in duration, (5) a mainstream business location, (5) direct pay by employer, and (6) at least minimum wage pay. The clubhouse develops and maintains a relationship with the employer in TE.

Group Placement (GP): Have all the characteristics of a regular TE as listed above except that it has at least one clubhouse staff on-site and involves more than one member at a time in the placement. Does not include any work in the clubhouse. These jobs may be referred to as an Enclave.

One-Day Job (DY): Job reserved for members who want to try out paid work in a mainstream setting for one to five day period. Must have all other characteristics of a regular TE.

Supported Employment (SE): A member-owned job where the clubhouse may make one or more job-site visits to: 1) develop the job, 2) develop/maintain a relationship with the employer, 3) provide job training, or 4) advocate for or express interpersonal support to the member. SE’s are not designed to be time-limited, may be full or part-time, and belong to the members employed in them. The clubhouse does not provide absence coverage but provides support on- and off-site upon the member’s request. These jobs are not “owned” by the clubhouse. Typically, there is a competitive element to the interview process and the employer (rather than the clubhouse placement manager) selects the employee.

Independent Employment (IE): A job for which the clubhouse provides support as requested by the member. There are no on-job-site services or responsibility to an employer. IE is distinguished from SE by the lack of a relationship between the employer and the clubhouse and absence of on-site supports. In IE, members participate in a fully competitive interview.

Other Employment: Any jobs that do not meet the criteria of Transitional Employment, Group Placement, One-Day Jobs, Supported Employment or Independent Employment. This may include Flex Jobs. Please check the types of employment programs your clubhouse sponsors:

______ Regular TE Positions (individual, time-limited jobs, owned by the clubhouse) ______ Group Placement (consistent hours, on-site staff, based on group not individual productivity) ______ One-day Jobs ______ Supported Employment ______ Independent Employment ______ Other Employment (describe): _________________________________________________)

Who pays the member directly? ( all that apply)

TE GP DY SE IE OTHER

EMPLOYER ____ ____ ____ ____ ____ ____ CLUBHOUSE ____ ____ ____ ____ ____ ____

PARENT AGENCY ____ ____ ____ ____ ____ ____ OTHER ____ ____ ____ ____ ____ ____ Your clubhouse’s usual vocational philosophy: ( all that apply; circle your primary philosophy)

Strong efforts for immediate job placement _____ Job skill training, then job placement _____ Readiness assessments, then job placement _____ Time in WOD, then job placement _____

Temporary work, then permanent work _____ No policy, member decides when to work ____ Please describe any cultural or local influences that affect your clubhouse as you seek to provide a Standards-based employment program.


Types of vocational supports provided by the clubhouse: (Please all that apply) TE GP DY SE IE Other (_____________) ____ Vocational Planning ___ ___ ___ ___ ___ ___ ____ Work Readiness Assessments ___ ___ ___ ___ ___ ___ ____ Job Skill Assessments ___ ___ ___ ___ ___ ___ ____ Life Skill Training/Hygiene ___ ___ ___ ___ ___ ___ ____ Help with Job Hunting/Resume Prep ___ ___ ___ ___ ___ ___ ____ Transportation to Job Interviews ___ ___ ___ ___ ___ ___ ____ Transportation to Work ___ ___ ___ ___ ___ ___ ____ Program-Sponsored/Program Owned Jobs ___ ___ ___ ___ ___ ___ ____ Job Development for Individual Members ___ ___ ___ ___ ___ ___ ____ On-Site Job Training ___ ___ ___ ___ ___ ___ ____ Off-Site Job Training ___ ___ ___ ___ ___ ___ ____ Advocacy with Employer ___ ___ ___ ___ ___ ___ ____ Coverage of Employee Absences ___ ___ ___ ___ ___ ___ ____ Formal Job Performance Assessments ___ ___ ___ ___ ___ ___ ____ Support Meetings (E.g. job clubs, TE dinners) ___ ___ ___ ___ ___ ___

Transitional Employment (TE) Is the clubhouse Transitional Employment program housed and staffed totally in the clubhouse? _____Yes _____No How often are visits made to TE job sites after the initial training period? (Select one)

____ At least daily ____ At least weekly ____ At least biweekly ____ At least monthly ____ Less than monthly

Are members encouraged to return to the clubhouse for the balance of the day? _____Yes _____No

Estimate the percentage that actually do. ______% Does the clubhouse guarantee coverage for TE positions, either by other members or by staff? _____Yes _____No

If yes, estimate the percentage of the TE absence that are actually covered. ________% How many clubhouse staff share TE placement management responsibilities? ________ (Enter number) Are there any staff whose exclusive responsibilities are supporting and developing the TE program? ___________ If yes, how many? ____________________ What is the average duration of a TE placement? (# of months) ___________________

11

Unless otherwise specified, please provide information on all Clubhouse-sponsored work for the same 3-month period used in the Membership Section on Page 4. Members Employed: Please report unduplicated counts of members in each job category, please follow employment definitions on page 9.

Transitional Employment

Group Placements

One-Day Jobs

Supported Employment

Independent Employment

Other Employment

During 3 month period: Number of members who worked for any length of time during the chosen 3-month period?

Number of members who worked a single job for at least two weeks during the chosen 3-month period?

Unduplicated number of members in each job category who worked for any length of time during the most recent fiscal year?

Number of members who worked for more than six months during the most recent fiscal year?

Total annual wages in each job category (most recent fiscal year)


Jobs: Please complete each section for each type of employment using the definitions on page 6.

Transitional Employment

Group Placements

One-Day Jobs

Supported Employment

Independent Employment

Other Employment

Number of different employers

Number of individual jobs

Number of job placements (Placement = the total number of individuals placed into jobs, may be a duplicated count) (One member may have multiple placements)

Average wage per job per hour

Range in wages per hour _____to_____ _____to_____ _____to_____ _____to_____ _____to_____ _____to_____

Number of jobs offering 0-5 hours/week

6-10 hours/week

11-15 hours/week

16-20 hours/week

21-25 hours/week

26-30 hours/week

31-35 hours/week

36-40 hours/week

Over 40 hours/week

13

Education Does your clubhouse have an education component? Yes_____ No______ Types of education programs that your clubhouse sponsors: ( all that apply)

_____ Classes and/or tutoring during the Work-ordered Day, taught by clubhouse staff _____ Classes and/or tutoring during the Work-ordered Day, taught by non-clubhouse teachers _____ Classes and/or tutoring during the Work-ordered Day, taught by clubhouse members _____ Classes and/or tutoring outside of the Work-ordered Day, taught by staff _____ Classes and/or tutoring outside of the Work-ordered Day, taught by non-clubhouse teachers _____ Classes and/or tutoring outside of the Work-ordered Day, taught by clubhouse members _____ Organized, unit-based assistance with applications, registration, financial aid, etc. for local adult education courses _____ On-going supports for members/students in local adult education courses (i.e. available computers; Education

dinners, tutoring, and assistance with assignments, etc.

Functions of the House

Please which services are provided directly to members by the clubhouse and circle or highlight the items which members are involved in the provision of the services.

___ Volunteer work to benefit the Clubhouse ___ Volunteer work to benefit other persons or programs ___ Transportation to clubhouse/appointments ___ Financial assistance with buying food or clothing ___ Low priced meals ___ Money management ___ Help with entitlements (e.g. pensions, SSI/SSDI) ___ Medication Administration ___ Links to physical health care/dental care ___ Psychiatric medication linkage, advocacy, or planning ___ Reimbursed case management ___ Non-reimbursed case management (e.g., needs assessment, service linkage & tracking) (e.g., needs assessment, service linkage & tracking) ___ Supported Education, GED classes ___ Arbitration of members’ disputes (e.g., applications to college, tutoring) (e.g., landlords, family, employers, benefits) ___ Help finding housing ___ Substance use/abuse intervention or education ___ 24-Hour crisis coverage (e.g., on-call staff, hotline) ___ Oversight of hospital admittance & discharge ___ Food Co-op ___ Reach Out, home or hospital visits ___ Mobile outreach ___ Peer support groups ___ Recreation, sports, cultural, or social activities ___ Programs/supports for family members ___ Child care or parenting help for consumers ___ Adolescent or young adult services ___ Geriatric services ___ Political advocacy, board positions, legislative testimony ___ Wellness, nutrition, &/or health ___ Linkage to local colleges and universities ___ Other:________________________________ ___ Other:_____________________________________ Circle or highlight the services above provided by members to members. Member Transportation: What is the primary means by which members get to and from clubhouse? ______% Walk ______% Car ______% Agency/Club van ______% Public transportation ______% Other (please specify): _________________________________________


Social/Recreational Program: What days and hours is your clubhouse open for social/recreational activities? Is your clubhouse open on all holidays? _____Yes _____No If no, why? Are holidays celebrated on the actual day of the holiday? _____Yes _____No If no, why? What kinds of social/recreational opportunities do you offer? Housing: What percentage of your membership lives in the following types of housing?

______% Independent housing ______% Clubhouse housing ______% Boarding house/group home ______% Living with family members ______% Without any or adequate housing ______% Unknown

Does your clubhouse have its own housing program? Yes_____ No_____ If yes: What types of housing does your clubhouse offer? __________________________________________________________________________________

If no, Does another housing program have slots reserved for clubhouse members? Yes_____ No_____

Does your clubhouse receive funding to provide housing? Yes_____ No_____ (Excluding Housing Funding that is sent to the Auspice/Parent agency)

If yes, Please indicate which items are covered by your housing funding: Rent Subsidies_____ Staff Salaries _____ Construction Costs_____ Security Deposits _______ Furniture _____ Other Household Items _____ Other (Describe):_______________________________ Who is responsible for managing this housing? _____ Clubhouse _____ Auspice (Parent) Agency _____ Case Management Team _____ Other (Describe):_______________________________ How many residents live in the clubhouse’s housing program now? ________ How many residents in your housing program are members of your clubhouse? ______ Are your housing services integrated into the clubhouse? Yes_____ No_____


Please indicate how housing services are provided at your clubhouse: _____ Housing staff or staff with housing responsibilities integrated within various units within the clubhouse _____ Housing staff belong to a separate unit & have generalist roles _____ Housing staff belong to a separate unit & do not have generalist roles _____Other – describe:________________________________________________________________________ What types of services are offered in your clubhouse’s housing program? ( all that apply)

Housing Support Generalist Staff Housing Funded Not Funded

24 hour beeper

Respite beds

Crisis intervention

Support services

Assistance finding housing

Transportation

Landlord negotiation

Clubhouse apartments

Other:__________________________

Substance Use/Abuse: Does your clubhouse offer any substance use education or support services? Yes_____ No_____ Please estimate the number of active members who meet the ICD-10 criteria for harmful use or substance dependence.

Definition Number of Members

Moderate Severe: members currently known to have a moderate/severe substance abuse problem

Mild Problems: members currently known to have a mild substance abuse problem

Abstinent: members with a known history of substance abuse problems but currently abstinent.

No Substance Abuse Problems

Unknown

Does your clubhouse currently screen for Substance Abuse? Yes_____ No_____ Does your clubhouse currently screen for Tobacco Dependence? Yes_____ No_____ *Tobacco use includes cigarettes, cigars, pipes, and smokeless tobacco (e.g. chewing tobacco).


Please estimate the number of active members (90 days) that are:

Substance Dependent:______________ Nicotine Dependent:______________________ Please estimate the number of active members (90 days) that are in the following categories:

Moderate/Severe Tobacco User:______________________ Abstinent/Former Tobacco User: _____________________ No Tobacco Use: ___________________

Reach Out/Outreach: Does your clubhouse have an outreach program? Yes_____ No_____ Monthly ‘On-call’ coverage:

‘Warm line’ clubhouse telephone counseling service _________ Telephone Counseling Hours/Month Clubhouse ‘hot line’ or on-call crisis services: _________ Total Coverage Hours/Month Other agency ‘on-call’ or crisis services: _________ Total Coverage Hours/Month (For example, hospital, CMHC, or auspice agency-funded service)

Advocacy/Case Management: Does your clubhouse currently provide advocacy and community support services to members? Yes_____No_____ Training Has the clubhouse Director participated in three week (or two week) ICCD Clubhouse Training? Yes_____ No_____

If yes, when and at which training base? ________________________________________ How many staff currently employed have participated in three-week ICCD Clubhouse Training at any international training base? ______

Staff name Which training base(s)? When? How many active members have participated in three week ICCD Clubhouse Training at any international training base?

Member name Which training base(s)? When? Who has attended the third week (administration/auspice) track of the ICCD Clubhouse Training from your house?

Name/Title Which training base(s)? When?


Record Keeping: Do you keep computerized records? Yes_____ No_____

Please check which of the following software programs or instruments your clubhouse utilizes to maintain clubhouse records

International Association of Psychosocial Rehabilitation Services (IAPSRS) TOOLKIT_________ Appilistic___________ A.W.A.R.D.S.___________ OTHER ______________________Describe:______________________________________________________

Does your clubhouse require a written or electronic rehabilitation and/or goal plan for active members? Yes_____ No_____ IF Yes, What percent of active members (90 days) have a current rehabilitation or goal plan?______________% Research Are you currently involved in a research project? Yes_____ No_____ Are you in the process of developing a research project? Yes_____ No_____

If you are involved in a research project &/or are developing a research project please provide the following information:

Project Title(s) Name(s) of primary contact(s) and/or lead investigator(s)

Is the project funded?

Funding Source(s)

Amount(s) Funded

Is your clubhouse interested in participating in a research project? Yes_____ No_____

If yes, Is there a specific question that you would like to address? Please describe: ___________________________

_________________________________________________________________________________________________ Do you have a collaborative working relationship with a university researcher or a researcher outside of your clubhouse? Yes_____ No_____ If yes, Who? ________________________________________________________________

Institutional Affiliation________________________________________________________________________

Telephone Number _______________________________

Email address____________________________________________

If no, Do you plan to have one in the future? Yes_____ No_____


FUNDING, GOVERNANCE, AND ADMINISTRATION Does your clubhouse try to meet all of the ICCD Clubhouse Standards? Yes_____ No_____ Are there standards with which your clubhouse is unable to comply? Yes_____ No_____ Please circle the standards numbers that are difficult for your clubhouse. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 What mode of decision-making do you use in your clubhouse? ( all that apply) ______ Voting ______ Consensus ______Other (describe: _________________________________) Which is your clubhouse’s primary model of decision making: ( one)

______ Voting ______ Consensus ______Other Organizational Structure How is the clubhouse managed and auspiced?

______ Free-standing, not for profit organization ______ Community Mental Health ______ Hospital ______ Municipal Government ______ County Government ______ Other (please specify): _________________________________________

Board of Directors Does your clubhouse have a Board of Directors? Yes_____ No_____ If yes, what are the board’s functions? (Please add any descriptive information available about the work of your board) How many Board members are clubhouse members? ____ If you do not have an independent governing body, does your clubhouse have an Advisory Board? Yes_____ No_____ If yes, what are its functions? How many Advisory Board members are clubhouse members? ___________


Clubhouse Associations: Does your clubhouse belong to any formal or informal association? Yes_____ No_____ If yes, please describe: Does your state/country have a clubhouse coalition? Yes_____ No_____

If yes, does your clubhouse belong to it? Yes_____ No_____ If yes, which coalition: ______________________________________________________________

In what ways has your clubhouse been active in the local coalition? Clubhouse Certification/Accreditation Is your clubhouse certified or accredited? Yes_____ No_____ _____ ICCD Certification: 1 Year _____ 3 Year Provisional _____ 3 Year _____ Date: __________

_____ Other: ________________________________________ Date: __________________ US CLUBHOUSES ONLY _____ JACHO (Joint Commission on Accreditation of Health 1-Year _____ 3-Year _____ Date: ___________ Care Organizations) _____ CARF (Commission on Accreditation of Rehabilitation Facilities) Date(s): ______________________ **************************************************************************************************

Please return this Clubhouse Profile Questionnaire immediately. Be sure to retain a copy for your records.

Thank You

Clubhouse Profile Questionnaire (CPQ) - 2009 - iccd.org · Clubhouse Profile Questionnaire (CPQ) - 2009. ... Vocational Rehab Agency ... Clubhouse Profile Questionnaire 2009 7 Please

Documents