Sample Questionnaires

Following are examples of ACORN questionnaires currently in use by various organizations.

To view summary outcome data for different questionnaires, diagnoses and payer plan type, see ACORN Toolkit Summary Results Viewer

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Adult questionnaires

Click on the questionnaire name to download a sample form.

• Adult Ver11
  • This is an example of a questionnaire intended for a general outpatient mental health population.
• Adult-SPMI
  • This questionnaire was developed for use with patients with severe and persistent mental illness who are receiving long term care in intensive outpatient or residential treatment programs.
• Adult Recovery Questionnaire
  • This questionnaire combines items from the global distress domain with items designed for use in 12-step based recovery programs which assess the client's progress towards recovery.
• Gambling Questionnaire
  • This questionnaire combines items from the global distress domain with items designed for use in gambling addictions recovery programs which assess the client's progress towards recovery.

Youth and child measures

• YouthOutcomeQuestionnaire-self.pdf
• YouthOutcomeQuestionnaire-caregiver.pdf
  • These two 16-item questionnaires are part of the Peabody Treatment Progress Battery
• YouthOutcomeQuestionnaire-caregiver-Ver2.pdf
• YouthOutcomeQuestionnaire-self-Ver2.pdf
  • These two questionnaires are caregiver and youth self report measures intended for youth ages 11 and up. These combine items from the Peabody Battery with items to rate the working alliance.

• ChildOutcomeQuestionnaire-caregiver.pdf
• ChildOutcomeQuestionnaire-self.pdf
  • These two questionnaires are caregiver and youth self report measures intended for children up the the age of 11. These combine items from the Peabody Battery with items to rate the working alliance.

Meta questionnaires

Meta questionnaires survey clients or clinicians believes and attitudes regarding the use of other questionnaires.

• ACORNQuestionnaireFeedbackForm-DRAFT.pdf
  • This questionnaire asks the client to give feedback on the ACORN questionnaires
  • This questionnaire is still in draft form while we seek input and comment from clinicians. If you have suggestions or are interested in using this questionnaires to get feedback from your clients, please contact jebbrown@clinical-informatics.com

ACORN Manual Table of Contents

Click on the following to view content

• Introduction
• Description of questionnaires
• Questionnaire Development
• Item Inventory
• Sample Questionnaires
• ACORN Normative Data
• Scoring the questionnaires
• Severity Ranges
• Reliability
• Validity
• Benchmarking Outcomes
• Monitoring change
• Alliance Scale
• ACORN Toolkit Summary Results Viewer
• ACORN Toolkit Help
• Outcomes Measurement Tutorial