Form Questionnaire

US Department of Health and Human Services

FORM NOT YET APPROVED
OMB. No. 0930-XXXX
APPROVAL EXPIRES: XX/XX/XXXX
See OMB burden statement on last page

Version 12/19/07

2008 National Survey of Mental Health
Treatment Facilities
Substance Abuse and Mental Health Services Administration
PLEASE REVIEW THE INFORMATION PRINTED BELOW IN THE LEFT COLUMN.
PLEASE MAKE ANY CORRECTIONS USING THE RIGHT COLUMN BELOW.
Current Information

FACILITY INFORMATION BOX

Corrections

Facility Name (Line 1)

Facility Name (Line 1)

Facility Name (Line 2)

Facility Name (Line 2)

Street Address

Street Address

Mailing Address (if different)

Mailing Address (if different)

City

State

Zip Code

Phone Number

(

)

-

ZipFour

City

Extension

Phone Number

-

(

Fax Number

State

Zip Code

ZipFour

Extension

)

-

-

)

-

-

Fax Number

(

)

-

-

(

Facility Director

Facility Director

Current Web Site Address -- If the web address in the box below is correct, please check here:

Corrected Web Site Address -- If the box above is blank or the web address is incorrect, enter the correct address below.

A. Is this the Main Administrative Facility? Yes

No

B. Are mental health services provided at this facility? Yes

(Go to the next page and continue with the questionnaire)
No
(Go to Question C)
C. Which of the following statements best describes this facility? <
CHECK ONE ONLY

It is an administrative facility only

It performs some other service. Please specify:

It provides substance abuse services
It provides developmental disability services
CMHS FACILITY ID

Draft

Please complete the contact information in Section E
(page 12) and return the questionnaire.
1

PLEASE READ THIS ENTIRE PAGE BEFORE
COMPLETING THE QUESTIONNAIRE

INSTRUCTIONS
Most of the questions in this questionnaire ask about this facility. By this facility we mean the specific treatment facility
whose name and location are printed in the Facility Information Box on the front cover. If you have any questions
about how the phrase this facility applies to your facility, please call the survey helpline at 1-800-722-6194.
[NOTE: If you have corrected the address, please consider the facility at the corrected address.]
Answer ONLY for the specific facility whose name and location are printed on the front cover, unless otherwise
specified in the questionnaire.
Return the completed questionnaire in the envelope provided. Please keep a copy for your records.
If you have any further questions or need additional blank forms, contact the survey helpline at:
1-800-722-6194
[email protected]
Or write to:
Social & Scientific Systems, Inc.
PO Box 8548
Silver Spring, MD 20907-9907

Would You Rather Complete the Questionnaire Online?
You can choose to respond to this questionnaire using the Internet at http://mhsurvey.s-3.com/. See the pink
information sheet enclosed in your questionnaire packet for your unique user ID and password. If this information
has been misplaced, please contact the survey helpline at 1-800-722-6194.

IMPORTANT INFORMATION
Information from asterisked (*) questions will be published in SAMHSA's online Mental Health Services Locator
and will be available online at http://mentalhealth.samhsa.gov/databases/.
Note that complete and accurate name and address information is needed for SAMHSA's online Mental Health
Services Locator so it can correctly map the facility's location.
Only facilities designated as eligible by SAMHSA will be listed in SAMHSA's online Mental Health Services
Locator. The orange information sheet included in your packet describes the criteria used to determine eligibility.
If you have any further concerns or questions regarding eligibilty, please contact the survey helpline
at 1-800-722-6194.

Draft

CMHS FACILITY ID
2

Questions? Call 1-800-722-6194

ANSWER ALL REMAINING QUESTIONS
FOR MENTAL HEALTH SERVICES ONLY.
(EXCLUDE ALL NON-MENTAL HEALTH
SERVICES FROM YOUR RESPONSES.)

SECTION A:
SERVICE CHARACTERISTICS
Section A asks about this facility's client/patients and
services. Remember: This questionnaire asks about this
facility only, the facility at the location listed in the Facility
Information Box on the front cover.

What telephone number(s) should a potential
client/patient call to schedule a mental health intake
appointment at this facility?

*4.

INTAKE TELEPHONE NUMBER(S)

1.

In which of following settings are mental health
services provided at this facility?

1.

(

) -

Extension

CHECK ALL SETTINGS THAT APPLY

24-hour hospital inpatient care
2.

(

) -

-

24-hour residential care

Extension

Less than 24-hour outpatient/partial care
*2.

4a. What are the hours of operation for the intake
telephone number(s)?

Are substance abuse services also provided at this
facility (the facility listed in the Facility Information Box
on the front cover of the questionnaire)?

From

AM__

AM__

To

PM__

Yes

CONTINUE WITH QUESTION 2a

No

SKIP TO QUESTION 3

Days of the Week:
This facility does not accept telephone calls for
mental health intake appointments.

*2a. In which of the following settings are
substance abuse services provided
at this facility?

*5.

(CHECK ALL SETTINGS THAT APPLY)

24-hour hospital inpatient care

Does this facility operate a 24/7 hotline that
responds to persons experiencing acute mental
health problems?
A hotline is a telephone service, available and staffed
24 hours a day, 7 days a week, that provides
information, referral, and immediate counseling to the
client/patient in a crisis situation.

24-hour residential care
Less than 24-hour outpatient/partial care
*3.

PM__

What is the primary service focus at this facility?

DO NOT consider 911, or the local police number, a
hotline for the purpose of this survey.

CHECK ONE ONLY

Mental health services

Yes

CONTINUE WITH QUESTION 5a

Substance abuse services

No

SKIP TO QUESTION 6

Mix of mental health and substance abuse services
(neither is primary)

*5a. Enter the hotline telephone number(s) below.

General health care (neither mental health nor
substance abuse services is primary)

HOTLINE TELEPHONE NUMBER(S):

Other service focus; please specify:

(

) -

Extension

(

) -

Extension

Draft

CMHS FACILITY ID
3

Questions? Call 1-800-722-6194

*6.

Which of the following mental health services are
provided at this facility? For definitions of mental health
services, please see the blue information sheet.

8.

CHECK ALL THAT APPLY

a.

Intake services

b.

Diagnostic evaluation

c.

Information and referral services

d.

Many people in recovery benefit from a number of
supportive practices. Which of the following are
provided by this facility? For definitions of the supportive
practices listed, please see the green information sheet.
CHECK ALL THAT APPLY

ADULTS
a.

Supported housing

Psychiatric emergency walk-in services

b.

Supported employment

Suicide prevention services

c.

f.

Case management

d.

Assertive community treatment
Family psychoeducation

g.

Psychosocial rehabilitation services

e.

Integrated dual disorders treatment

f.

Illness management and recovery (IMR)

e.

h.

Vocational rehabilitation services

i.

Legal advocacy

CHILDREN/ADOLESCENTS

j.

Education services

g.

k.

Housing services

h.

l.

Consumer-run services

m.

Chronic disease/illness management

n.

Other; please specify:

i.

9.

Therapeutic foster care
Multisystemic therapy
Functional family therapy

Does an acute care crisis intervention treatment team
operate from this facility?
Yes, within facility only
Yes, off site only
Yes, within facility and off site

*7.

No

Which of the following mental health treatment
approaches are provided at this facility? For definitions
of mental health treatment approaches, please see the
purple information sheet.

*10.

Please identify the following functions at your facility
that are accomplished using computerized systems:
a.

Computerized results reporting (e.g., laboratory results,
psychological testing)

b.

Computerized Physician Order Entry (CPOE) or
outpatient prescriptions/directions

c.
d.

Sending to and receiving clinical data from other
providers
Creating and transmitting referrals to other providers or
services (e.g., employment placement, housing
assistance, vocational training)

e.

Treatment plan creation and maintenance

CHECK ALL THAT APPLY

a.

Interpersonal psychotherapy

b.

Group therapy

c.

Couples counseling/family therapy

d.

Behavior modification

e.

Cognitive/Behavioral therapy

f.

Activity therapy

g.

Electroconvulsive therapy

h.

Psychotropic medication therapy

i.

Other; please specify:

Functional family therapy

Problem list creation and maintenance
Medication interaction checking

h.

Billing/claims preparation and submission

i.
j.

Patient scheduling
Process note-taking

k.

Other; please specify:

f.

Draft

CMHS FACILITY ID
i.

g.

4

Questions? Call 1-800-722-6194
*11.

Indicate which age/gender categories of client/patients
are accepted for treatment at this facility?

15.
.

Indicate whether the following quality assurance
practices are in place at this facility?

CHECK YES OR NO FOR EACH CATEGORY
CHECK YES OR NO FOR EACH PRACTICE

YES

NO

a. Children/adolescents

YES

(17 or younger)
b. Adult women (18-64)

NO

a. Required continuing education

for staff

c. Adult men (18-64)
b. Regularly scheduled case review

d. Seniors (65 or Older)

*12.

with a supervisor
c. Regularly scheduled case review by

Indicate whether the specially designed service
programs listed below are provided at this facility.

an appointed quality review committee
d. Client/patient outcome follow-up

CHECK YES OR NO FOR EACH SPECIAL PROGRAM TYPE

YES

after discharge

NO

a. Specially designed program to

e. Periodic utilization review

treat children who are severely
emotionally disturbed (SED)
b. Specially designed program to
treat adults with severe and
persistent mental illness (SPMI)
c. Specially designed program to
treat seniors with Alzheimer's/
dementia
d. Specially designed program to
treat persons with co-occurring
mental illness and substance
abuse disorders

f. Periodic client/patient

satisfaction surveys
16.
.

b. Has training been provided to staff

e. Specially designed program to

at this facility on alternatives to
seclusion and restraint practices?

treat forensic (referred from your
State's judicial system)
client/patients
f. Specially designed programs to
treat post-traumatic stress disorder

SECTION B: GENERAL
FACILITY CHARACTERISTICS

g. Other special program; please specify:

17.
*13.

Does this facility provide mental health services for the
hearing-impaired?
Yes
No

*14.
.

Publish
Do not publish; please explain:

CHECK ALL THAT APPLY

English

b.

Spanish

c.

Other; please specify:

Sometimes there is a reason (e.g., the facility is
primarily a residence) when a mental health facility
would not want to be listed in a public directory.
Indicate below whether this facility (the facility listed in
the Facility Information Box on the front cover of the
questionnaire) should, or should not, be published in
SAMHSA's online Mental Health Services Locator?
CHECK ONE ONLY

In what languages does staff provide mental health
services at this facility?

a.

In the 12-month period beginning January 1, 2007, and
ending December 31, 2007:
YES
NO
a. Have staff at this facility used
seclusion or restraint practices with
clients?

Draft

CMHS FACILITY ID
5

Questions? Call 1-800-722-6194
*18.

23.

Check one box below that best describes this type of
facility (the facility listed in the Facility Information Box
on the front cover of the questionnaire). Use the yellow
information sheet, Mental Health Facilities Type
Definitions, to classify this facility correctly.

.

Does this facility offer treatment at no charge to
client/patients who cannot afford to pay? Note that the
answer to this question will not be published in SAMHSA's
online Mental Health Services Locator.
Yes

CHECK ONE ONLY

No

Psychiatric hospital
24.

Residential treatment center for emotionally disturbed
children
Residential treatment center for adults

.

Separate psychiatric unit of a general hospital

CHECK ALL THAT APPLY

a.

Medicaid

b.

Medicare

c.

State mental health agency (or equivalent) funds

d.

Other state government funds; specify:

A private partnership
A private corporation

e.

Local government funds

State mental health agency (SMHA)

f.

Other public funds; specify:

Outpatient/partial care mental health facility
Multi-setting (non-hospital) mental health facility
Other; please specify:

*19.

Which of the following types of client/patient payments
(direct or indirect) or insurance are accepted by this
facility for mental health services?

This facility is owned by:
CHECK ONE ONLY

State government (e.g., Department of Health)
other than the SMHA
Regional/district (e.g., hospital district authority)
County government
City or municipal government
Other; please describe:

20.

g.

Community Service Block Grants

h.

Community Mental Health Block Grants

i.

Other Federal block grants; specify:

j.

Client/patient fees

k.

Private Insurance

l.

Other private funds; specify:

Is this facility part of a for-profit or part of a non-profit
organization?
CHECK ONE ONLY

For-profit
Non-profit (includes not-for-profit)
*21.

Is this facility affiliated with a religious organization?

.

Yes; please specify:

No
22.
.

Does this facility use a sliding fee scale? Note that the
answer to this question will not be published in SAMHSA's
online Mental Health Services Locator.
Yes
No

Draft

CMHS FACILITY ID
No

6

Questions? Call 1-800-722-6194
25.
.

27.

Does this facility provide mental health treatment
services through any managed care organizations
(MCOs)?

.

If available, enter the National Provider Identifier (NPI)
for this facility.
NPI

Managed care plans have arrangements with certain
health care providers who give services to plan
members, usually at discounted rates. Examples
include managed behavioral healthcare organizations
(MBHOs), health maintenance organizations (HMOs),
and preferred provider organizations (PPOs).

SECTION C: CLIENT/PATIENT
COUNTS
IMPORTANT: Questions in this section ask for counts at
different time periods, e.g., the single day of
December 31, 2007, the month of December 2007, the last 90
days before December 31, 2007, and the full 12-month period
ending on December 31, 2007. Please pay close attention to
the time period specified in each question. If the counts are not
available for December 31, 2007, use the last day of the most
recent month for which data are available.

Yes - Continue with Q25a
No - Skip to Q26
*25a. What is the main MCO through which
your facility provides mental health
treatment services? Please specify:

Include in your counts all client/patients receiving mental health
treatment, even if mental health is their secondary diagnosis or
if a mental illness has not yet been formally determined.
*26.
.

Does this facility have licensing, certification, or
accreditation from any of the following organizations?

28.
.

Include only licensing, accreditation, etc., related to the
provision of behavioral health services.
Do not include general business licenses, fire marshal
approvals, personal-level credentials, food service
licenses, etc.

For the client/patient counts requested in this section,
indicate below the number of facilities that are
included in your counts. Although counts for this
facility only are preferred, it may be that you are unable
to break your data down into separate facilities.
Only this facility
This facility plus others

CHECK YES OR NO FOR EACH CATEGORY

YES

NO

This Facility

1

a. State mental health agency

+ Additional Facilities
b. State substance abuse agency

= Total Facilities
c. State department of health

When we receive your questionnaire, we will contact you for
a list of the other facilities included in your client counts.

d. Hospital licensing authority
e. JCAHO (Joint Commission on

Accreditation of Healthcare
Organizations)

IMPORTANT: The questions in this section ask for counts
or percents based on the service settings you checked in
question 1 at the beginning of the questionnaire.

f. CARF (Commission on Accreditation

of Rehabilitation Facilities)

If you checked 24-Hour Hospital Inpatient Setting,
complete Section C1.

g. NCQA (National Committee for

If you checked 24-Hour Residential Care Setting,
complete Section C2.

Quality Assurrance)
h. COA (Council on Accreditation for

If you checked Less than 24-Hour Outpatient/Partial
Care Setting, complete Section C3.

Children & Family Services)
i. Another state or local agency or

other organization; please specify:

Section C4 (and the remainder of the questionnaire)
should be completed by all mental health providers.

Draft

CMHS FACILITY ID
7

Questions? Call 1-800-722-6194
29b. For each category below enter either the number
.
or the percent of client/patients from the HOSPITAL
INPATIENT TOTAL BOX in Question 29a.

SECTION C1: 24-HOUR HOSPITAL
INPATIENT CARE SETTING
29.
.

Using the total number of client/patients specified in
Question 29a, please give a breakdown of the client/patient
population for each category below. You may use numbers
(#) OR percents (%). Numbers in each box should add to
the total in Question 29a. Percents should add to 100%.

On December 31, 2007, did any client/patients receive
mental health services in a 24-hour hospital inpatient
care setting at this facility (the facility listed in the
Facility Information Box on the front cover of the
questionnaire)?

USE NUMBERS (#) OR PERCENTS (%)
SEX

Yes

ANSWER QUESTIONS 29a, 29b, AND 29c

No

SKIP TO QUESTION 30

29a.
.

#

%

TOTAL= Q29a

100%

#

%

TOTAL= Q29a

100%

#

%

TOTAL= Q29a

100%

#

%

TOTAL= Q29a

100%

#

%

TOTAL= Q29a

100%

Male
Female

On December 31, 2007, how many
client/patients received mental health
services in a 24-hour hospital inpatient care
setting at this facility?

AGE
0-17

DO NOT count family members, friends, or
other non-treatment client/patients

18-64
65 & up

HOSPITAL INPATIENT
TOTAL BOX
ETHNICITY
Hispanic
Non-Hispanic

RACE
White
Black
American Indian
or Alaskan Native
Asian or Pacific Islander
Mixed Race

LEGAL STATUS
Voluntary
Involuntary, non-forensic
Involuntary, forensic

Draft

CMHS FACILITY ID
8

Questions? Call 1-800-722-6194

29c.
.

30b. For each category below enter either the number
.
or the percent of client/patients from the RESIDENTIAL
TOTAL BOX in Question 30a.

On December 31, 2007, how many hospital
inpatient beds at this facility were set up and
staffed for the provision of mental health
services?

Using the total number of client/patients specified in
Question 30a, please give a breakdown of the client/patient
population for each category below. You may use numbers
(#) OR percents (%). Numbers in each box should add to
the total in Question 30a. Percents should add to 100%.

ENTER A NUMBER
(IF NONE WERE SET UP
ON DECEMBER 31, ENTER "0")

USE NUMBERS (#) OR PERCENTS (%)
Number of beds

SEX

TOTAL= Q30a

100%

#

%

TOTAL= Q30a

100%

#

%

TOTAL= Q30a

100%

#

%

TOTAL= Q30a

100%

#

%

TOTAL= Q30a

100%

Female

AGE
.

%

Male

SECTION C2: 24-HOUR RESIDENTIAL
CARE SETTING

30.

#

On December 31, 2007, did any client/patients receive
mental health services in a 24-hour residential care
setting at this facility (the facility listed in the Facility
Information Box on the front cover of the
questionnaire)?

0-17
18-64
65 & up

Yes

ANSWER QUESTIONS 30a, 30b, AND 30c

No

SKIP TO QUESTION 31

30a.
.

ETHNICITY

On December 31, 2007, how many
client/patients received mental health
services in a 24-hour residential care
setting at this facility?

Hispanic
Non-Hispanic

DO NOT count family members, friends, or
other non-treatment client/patients

RACE
White

RESIDENTIAL

Black

TOTAL BOX

American Indian
or Alaskan Native
Asian or Pacific Islander
Mixed Race

LEGAL STATUS
Voluntary
Involuntary, non-forensic
Involuntary, forensic

Draft

CMHS FACILITY ID
9

Questions? Call 1-800-722-6194
31b.

30c. On December 31, 2007, how many residential
.
beds at this facility were set up and staffed
for the provision of mental health services?

.

For each category below enter either the number
or the percent of client/patients from the OUTPATIENT
TOTAL BOX in Question 31a.
Using the total number of client/patients specified in
Question 31a, please give a breakdown of the client/patient
population for each category below. You may use numbers
(#) OR percents (%). Numbers in each box should add to
the total in Question 31a. Percents should add to 100%.

ENTER A NUMBER
(IF NONE WERE SET UP
ON DECEMBER 31, ENTER "0")

USE NUMBERS (#) OR PERCENTS (%)

Number of beds
SEX

SECTION C3: LESS THAN 24-HOUR
OUTPATIENT/PARTIAL
CARE SETTING

.

%

TOTAL= Q31a

100%

#

%

TOTAL= Q31a

100%

#

%

TOTAL= Q31a

100%

#

%

TOTAL= Q31a

100%

#

%

Male
Female

AGE
31.

#

During the month of December 2007, did any
client/patients receive mental health services in an
outpatient care setting at this facility (the facility listed
in the Facility Information Box on the front cover of
the questionnaire)?

0-17
18-64
65 & up

Yes

ANSWER QUESTIONS 31a AND 31b

No

SKIP TO QUESTION 32

31a.
.

ETHNICITY
Hispanic

As of December 31, 2007, how many active
client/patients were enrolled for services in
an outpatient care setting at this facility?

Non-Hispanic

An active outpatient client/patient is someone
who: (1) was seen at this facility at least once
during the 90 days before December 31, 2007;
AND
(2) was still enrolled in treatment on
December 31, 2007.

RACE
White
Black

DO NOT count family members, friends, or
other non-treatment client/patients

American Indian
or Alaskan Native

OUTPATIENT

Asian or Pacific Islander

TOTAL BOX

Mixed Race

LEGAL STATUS
Voluntary
Involuntary, non-forensic
Involuntary, forensic

TOTAL= Q31a

100%
Draft

CMHS FACILITY ID
10

Questions? Call 1-800-722-6194

SECTION C4: ALL MENTAL HEALTH
CARE SETTINGS
32.
.

.

Please use the box below to elaborate on any of the
information requested or provided in this questionnaire.
Use additional sheets of paper if more space is needed.
If applicable, indicate the number of the question to
which your comments refer.

Approximately what percent of the mental health
treatment client/patients enrolled on
December 31, 2007, at the facility listed in the Facility
Information Box on the front cover of the
questionnaire, had a diagnosed co-occurring mental
health and substance abuse disorder?
%

PERCENT OF CLIENT/PATIENTS
(IF NONE, ENTER "0")
33.

SECTION D: COMMENTS

In the 12-month period beginning January 1, 2007, and
ending December 31, 2007, what was the total number
of admissions, readmissions, and transfers to this
facility that received mental health treatment? Count
every admission and re-admission in this 12-month period.
If a person was admitted 3 times, count this as
3 admissions. Exclude returns from unauthorized absence
(escape, AWOL, elopement).
FOR OUTPATIENT CLIENT/PATIENTS,
consider an admission to be the initiation of a course
of treatment. Count admissions into treatment, not
individual treatment visits.
IF DATA FOR THIS TIME PERIOD are not available,
use the most recent 12-month period for which data are
available.
Count all admissions in which client/patients received
mental health treatment, even if mental health was their
secondary diagnosis.
NUMBER OF MENTAL
HEALTH ADMISSIONS
IN 12-MONTH PERIOD

34.
.

Of the total number of admissions listed in the box
above, what proportion were military veterans?
Please give your best estimate

%

Data collected but not available
Data not collected

Draft

CMHS FACILITY ID
11

Questions? Call 1-800-722-6194

SECTION E: CONTACT INFORMATION
Person Responsible for Completing This Survey

CHECK ONE ONLY

Ms.

Miss

Mrs.

Mr.

Dr.

Other; please specify:

First Name

Last Name

Title

Email Address

Phone Number

(

Extension

) -

-

) -

-

Fax Number

(

Thank you for your participation. Please return this questionnaire in the

envelope provided. If you no longer have the envelope, please mail this
questionnaire to:
Social & Scientific Systems, Inc.
P.O. Box 8548
Silver Spring, MD 20907-9907

Public burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA
Reports Clearance Officer, Room 7-1044, 1 Choke Cherry Road, Rockville, Maryland 20857. An agency may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this
project is 0930-XXXX.

Draft

CMHS FACILITY ID
12