Cultural Understanding Assessment

Cultural Understanding Assessment - Client Form
Component Location

FOH ResidentialFOH Outpatient (1108 Lapeer Rd, 505 Court St, 718 Oak St)CICFOH Port Huron (Outpatient, Recovery Housing, Mort)SOH (Residential, Outpatient, Recovery Housing)DetoxPrevention / EWSS/ EPPSTRIVE
What is your sex?

MaleFemale
What is your race?

Alaskan NativeAmerican IndianAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderWhite
Are you Hispanic or Latino

YesNo
Strongly Disagree = 1 / Diagree = 2 / Neither Agree or Disagree = 3 / Agree = 4 / Strongly Agree = 5
1. The staff here understand some of the ideas that I, my family, and others from my cultural, racial, or ethnic group may have.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
2. Staff here understands the importance of my cultural beliefs in my 1 2 3 4 5treatment process.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
3. The staff here listens to me and my family when we talk to them.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
4. If I want, the staff will help me get services from clergy or spiritual leaders.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
5. The services I get here really help me work toward things like getting a job, taking care of my family, going to school, and being active with my friends, family, and community.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
6. The staff here seems to understand the experiences and problems I have in my past life.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
7. The waiting room and/or facility has pictures or reading material that show people from my racial or ethnic group.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
8. The staff here knows how to use their knowledge of my culture to help me address my current day-to-day needs.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
9. The staff here understands that I might want to talk to a person from my own racial or ethnic group about getting the help I want.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
10. The staff here respects my religious or spiritual beliefs.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
11. Staff from this program comes to my community to let people like me and others know about the services they offer and how to get them.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
12. The staff here asks me, my family, or others close to me to fill out forms that tell them what we think of the place and services.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
13. Staff here understands that people of my racial or ethnic group are notall alike.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
14. It was easy to get information I needed about housing, food, cloth-ing, child care, and other social services from this place.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
15. The staff here talks to me about the treatment they will give me to help me.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
16. The staff here treats me with respect.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
17. The staff seems to understand that I might feel more comfortable working with someone who is the same sex as me.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
18. Most of the time, I feel I can trust the staff here who work with me

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
19. The waiting room has brochures or handouts that I can easily understand that tell me about services I can get here.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
20. If I want, my family or friends are included in discussions about the help I need.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
21. The services I get here deal with the problems that affect my day-to- ay life such as family, work, money, relationships, etc.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
22. Some of the staff here under-stand the difference between their culture and mine.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
23. Some of the counselors are from my racial or ethnic group.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
24. Staff members are willing to be flexible and provide alternative approaches or services to meet my cultural/ethnic treatment needs.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
25. If I need it, there are translators or interpreters easily available to assist me and/or my family.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
Should be Empty:

Cultural Understanding Assessment - Client Form

Strongly Disagree = 1 / Diagree = 2 / Neither Agree or Disagree = 3 / Agree = 4 / Strongly Agree = 5