PHB Closure measure

PHB Closure measure
Recovery goals/PHB Closure
Are you able to engage the PHB holder in this closure?*

YesNo
Referrer name*

First NameLast Name
Borough*
Email address*
example@example.com
Review date*

DayMonthYear
Date
PHB holder name*

First NameLast Name
PHB package number*
NHS number*
Please explain the reason why (disengaged, increase in care etc)*
Please outline any benefits you have been made aware of as part of supporting this PHB*
Please tell us how much you agree or disagree with this statement:
"The Personal Health Budget has supported me to work towards my mental health recovery goal"**
Please tell us a little more about why you have selected the answer above**
Do you have further recovery goals you would like to be supported with*

YesNo
Please detail*
Additional information
Is there anything else you wish to share about your Personal Health Budget experience?*
What if anything, would have made your PHB experience better or improved?*
Please select an outcome measure*
DIALOG+ monitoring
1 – Totally dissatisfied

2 – Very dissatisfied

3 – Fairly dissatisfied

4 – In the middle

5 – Fairly satisfied

6 – Very satisfied

7 – Totally satisfied
How satisfied are you with your mental health?*
How satisfied are you with your physical health?*
How satisfied are you with your job situation?*
How satisfied are you with your accommodation?*
How satisfied are you with your leisure activities?*
How satisfied are you with your relationship with your partner/family?*
How satisfied are you with your friendships?*
How satisfied are you with your personal safety?*
How satisfied are you with your medication?*
How satisfied are you with the practical help you receive?*
How satisfied are you with your meetings with mental health professionals?*
ReQoL/10 monitoring
Answer the following question in relation to last week.

4 – None of the time

3 – Only occasionally

2 – Sometimes

1 – Often

0 – Most of the time
I found it difficult to get started with everyday tasks*
Answer the following question in relation to last week.

0 – None of the time

1 – Only occasionally

2 – Sometimes

3 – Most of the time

4 – Most or all of the time
I felt able to trust others*
Answer the following question in relation to last week.

4 – None of the time

3 – Only occasionally

2 – Sometimes

1 – Often

0 – Most of the time
I felt unable to cope*
Answer the following two questions in relation to last week.

0 – None of the time

1 – Only occasionally

2 – Sometimes

3 – Most of the time

4 – Most or all of the time
I could do the things I wanted to do*
I felt happy*
Answer the following question in relation to last week.

4 – None of the time

3 – Only occasionally

2 – Sometimes

1 – Often

0 – Most of the time
I thought my life was not worth living*
Answer the following two questions in relation to last week.

0 – None of the time

1 – Only occasionally

2 – Sometimes

3 – Most of the time

4 – Most or all of the time
I enjoyed what I did*
I felt hopeful about my future*
Answer the following question in relation to last week.

4 – None of the time

3 – Only occasionally

2 – Sometimes

1 – Often

0 – Most of the time
I felt lonely*
Answer the following question in relation to last week.

0 – None of the time

1 – Only occasionally

2 – Sometimes

3 – Most of the time

4 – Most or all of the time
I felt confident in myself*
Feedback; experience of the Personal Health Budget (optional)
Please tell us how much you agree or disagree with the following statements:
"I would recommend this service"**
"I was able to get what I needed to support my mental health recovery goal"**
"I felt I had choice and control over my recovery plan"**
"I benefited from what my personal health budget enabled me to do"**
Should be Empty:

PHB Closure measure

Recovery goals/PHB Closure

Additional information

DIALOG+ monitoring

ReQoL/10 monitoring

Feedback; experience of the Personal Health Budget (optional)