CATI Questionnaire

Attachment A.3 (N-MHSS-Locator CATI Questionnaire)

2012 NATIONAL MENTAL HEALTH SERVICES SURVEY-LOCATOR SURVEY

Hello Hello, my name is [fill interviewer name] and I am calling concerning the Federal Government’s survey of mental health service providers called the National Mental Health Services Survey-Locator Survey. The N-MHSS-Locator Survey is sponsored by SAMHSA, the Substance Abuse and Mental Health Services Administration.

GetDir May I speak with [fill director name] regarding this facility’s 2012 N-MHSS-Locator Survey?

USE UpdateInfo TAB TO ENTER A DIFFERENT PHONE NUMBER

<1> SPEAKING WITH FACILITY DIRECTOR/APPROPRIATE PERSON

[goto Intro]

<2> CONNECTED TO FACILITY DIRECTOR/APPROPRIATE PERSON

[goto Hello2]

<3> FACILITY DIRECTOR NOT AVAILABLE [goto Callback]

<4> ANSWERING MACHINE [goto Message_Q]

<5> WRONG NUMBER [goto Sorry]

Sorry I’m sorry. Thank you for your time.

Hello2 Hello, my name is [fill interviewer name] and I am calling concerning the Federal Government’s survey of mental health service providers called the National Mental Health Services Survey-Locator Survey. The N-MHSS-Locator Survey is sponsored by SAMHSA, the Substance Abuse and Mental Health Services Administration.

[goto Intro]

Intro Recently you were mailed a letter from Dr. H. Wesley Clark at SAMHSA. This letter requested the participation of your facility in the 2012 N-MHSS-Locator Survey. We are calling at this time to complete the survey. Is this a good time?

<1> YES, CONTINUE [goto Confirm2]

<2> SCHEDULE CALLBACK AT CONVENIENT TIME [goto Callback]

<3> COMPLETING ON THE WEB [Thanks]

<4> NO LONGER PROVIDES MENTAL HEALTH SERVICES [goto a1a]

<5> NEVER PROVIDED MENTAL HEALTH SERVICES [goto a1a]

<6> DUPLICATE FACILITY [goto Duplicate]

<7> MERGED WITH ANOTHER FACILITY [goto Merged]

<8> FACILITY CLOSED/NO LONGER EXISTS [goto Thanks2]

<9> WRONG NUMBER [goto Sorry]

Confirm2 I will be asking you questions about [fill facility name] Located at

[fill address 1]

[fill address 2]

[fill City],

[fill State]

[fill zip]

IF NOT CORRECT USE THE UpdateInfo TAB TO UPDATE FACILITY

INFORMATION

[goto A1]

RE3 Who could answer facility-specific questions such as which types of services are offered at this facility?

USE UpdateInfo TAB TO ENTER A NEW CONTACT NAME

RE4 Could I speak with [fill contact name]?

<1> YES [goto RE5]

<2> NOT AVAILABLE – INTERVIEWER: Thank you, I will call

back. [goto Callback]

<3> CONNECTED TO ANSWERING MACHINE [goto Message_R]

RE5 Hello, my name is [fill interviewer name] and I am calling on behalf of the Federal Government’s survey of mental health services called the National Mental Health Services Survey- Locator Survey. This survey is sponsored by SAMHSA, the Substance Abuse and Mental Health Services Administration. I have a few questions I’d like to ask you.

<1> YES, CONTINUE [goto A1]

<2> NO, NOT A CONVENIENT TIME [goto Callback]

<3> NO, WILL COMPLETE ON WEB [goto Thanks]

Duplicate Which facility is a duplicate of this one?

PRESS ENTER TO CHOOSE FROM LIST OR TO ENTER FACILITY INFO[choose from list of facilities or goto MainFacility]

Merged Which facility was this one merged with?

PRESS ENTER TO CHOOSE FROM LIST OR TO ENTER FACILITY INFO[choose from list of facilities or goto MainFacility]

MainFacility May I have the name, address and phone number of the facility?

<1> CONTINUE

PhoneNumber Please give me the telephone number, area code first.

[goto Thanks]

Message_Q ***QUESTIONNAIRE CALL MESSAGE***

DID YOU LEAVE THE MESSAGE?

<1> YES

<2> NO

Thanks Thank you so much for your time. Your responses are very important to the study and we look forward to receiving your completed questionnaire.

Thanks2 Thank you for your time.

Callback USE THE ‘APPOINTMENT’ TAB ABOVE TO MAKE AN APPOINTMENT.

A1 First, I will ask you about the characteristics of the individual facility, [fill facility name] located at [fill location address].

Please answer the following questions referring only to this Mental health facility.

<1> CONTINUE TO a1b

A1a Please confirm if any of the following services are offered at this location.

<1> CONTINUE TO a1b

A1b Does this facility, at this location, [fill location address], offer:

YES NO

Mental health intake services (1) (0)

Mental health diagnostic evaluation (1) (0)

Mental health information and referral services (1) (0)

(also includes emergency programs that

provide services in person or by

telephone)

Mental health treatment services (1) (0)

(services focused on improving the mental

well-being of individuals with mental

disorders and on promoting their recovery)

[if NO, goto B1]

Substance abuse treatment services (1) (0)

Administrative services (1) (0)

(d) DON’T KNOW

(r) REFUSED

A3 In which of these settings are mental health treatment services offered at this facility, at this location?

YES NO

24-hour hospital inpatient setting (1) (0)

(psychiatric hospital or general hospital

with a separate psychiatric unit)

24-hour residential setting (1) (0)

(24-hour, overnight, psychiatric care in

a residential non-inpatient setting such

as a residential treatment center for

adults or children)

Day treatment or partial hospitalization

setting (1) (0)

(structured programs of treatment, activity,

or other mental health services provided in

clusters of 3 or more hours per day)

Outpatient mental health setting (1) (0)

(programs of mental health services

provided to clients on an hourly schedule,

on an individual or group basis)

(d) DON’T KNOW

(r) REFUSED

A4 Which one category best describes this facility, at this location?

INTERVIEWER: FOR DEFINITIONS OF FACILITY TYPES CLICK HERE

INTERVIEWER: CODE ONE ONLY

<1> Psychiatric hospital [goto a6]

<2> Separate inpatient psychiatric unit of a general hospital

IF CATEGORY <2> IS CODED DISPLAY: Consider this psychiatric unit as the relevant entity when the word ”facility” is used in this survey [goto a6]

<3> Residential treatment center for children [goto a6]

<4> Residential treatment center for adults [goto a6]

<5> Outpatient or day treatment or partial hospitalization

mental health facility

<6> Multi-setting mental health facility (non-hospital

residential plus outpatient or day treatment

or partial hospitalization)

<7> Other (SPECIFY) [specify] END WITH //

<d> DON’T KNOW

<r> REFUSED

A5 Is this facility a solo practice or small group practice?

PROBE IF NECESSARY: Please answer “yes” or “no” for this question.

<1> YES

<0> NO [goto a6]

<d> DON’T KNOW

<r> REFUSED

A5a Is this facility licensed or accredited as a mental health clinic or mental health center?

PROBE IF NECESSARY: Do not count the licenses or credentials of individual practitioners.

<1> YES

<0> NO [goto b1]

<d> DON’T KNOW

<r> REFUSED

A6 Is this facility a jail, prison, or detention center that provides treatment exclusively for incarcerated persons or juvenile detainees?

<1> YES

<0> NO [goto a7]

<d> DON’T KNOW [goto a7]

<r> REFUSED [goto a7]

A6a Just to confirm, this facility provides mental health treatment services only to incarcerated persons or juvenile detainees. Is that correct?

<1> YES, THAT IS CORRECT [goto b1]

<0> NO, THAT IS NOT CORRECT

A7 Is this facility operated by:

INTERVIEWER: CODE ONE ONLY

<1> a private for-profit organization [goto a8]

<2> a private non-profit organization [goto a8]

<3> state mental health agency (SMHA) [goto a8]

<4> other state government agency or department

(such as, Department of Health) [goto a8]

<5> regional/district authority or local, county

or municipal government [goto a8]

<6> tribal government [goto a8]

<7> U.S. Federal agency [goto a7a]

<8> Other (SPECIFY) [specify] END WITH // [goto a8]

<d> DON’T KNOW

<r> REFUSED

A7a Which U.S. Federal agency is this facility operated by:

INTERVIEWER: CODE ONE ONLY

<1> Department of Veterans Affairs

<2> Department of Defense

<3> Indian Health Service

<4> Other Federal agency (SPECIFY) [specify] END WITH //

<d> DON’T KNOW

<r> REFUSED

A8 Does this facility, at [fill location address], provide treatment services that specifically address:

YES NO

Schizophrenia or other psychoses (1) (0)

Mood disorders (such as, bipolar, depression) (1) (0)

Autism/autism spectrum disorders (1) (0)

Attention deficit or conduct disorders

(such as, ADHD, disruptive behavior disorder) (1) (0)

Anxiety disorders (such as, PTSD, obsessive-

compulsive disorder, phobia disorder) (1) (0)

Eating disorders (such as, anorexia nervosa,

bulimia) (1) (0)

Other (SPECIFY) [specify] END WITH // (1) (0)

(d) DON’T KNOW

(r) REFUSED

A9 What age groups are accepted for treatment

at this facility?

YES NO

<1> Children (aged 17 or younger) (1) (0)

<2> Young adults (18-25) (1) (0)

<3> Adults (26 or older) (1) (0)

(d) DON’T KNOW

(r) REFUSED

A10a The next series of questions asks what types of clients are treated at this location. For each type of client treated at this facility, I will ask if this facility has a specially-designed mental health treatment program or group exclusively designed for that type of client.

Does [fill facility name] treat [fill with client types 1-12) at this location?

YES NO

Children with serious emotional disturbance (SED) (1) (0)

Adults with serious mental illness (SMI) (1) (0)

Seniors or older adults (1) (0)

Individuals with Alzheimer’s or dementia (1) (0)

Individuals with co-occurring mental and substance

abuse disorders (1) (0)

Individuals with post-traumatic stress

disorder (PTSD) (1) (0)

Veterans (1) (0)

Active duty military (1) (0)

Members of military families (1) (0)

Individuals with traumatic brain injury (TBI) (1) (0)

Lesbian, gay, bisexual, transgender, or

questioning clients (LGBTQ) (1) (0)

Forensic clients (referred from the court/

judicial system) (1) (0)

(d) DON’T KNOW

(r) REFUSED

A10b [ask for all A10a1-12 = <1>]]

Does this facility offer a specially-designed mental health treatment program or group exclusively for…

YES NO

Children with serious emotional disturbance (SED) (1) (0)

Adults with serious mental illness (SMI) (1) (0)

Seniors or older adults (1) (0)

Individuals with Alzheimer’s or dementia (1) (0)

Individuals with co-occurring mental and substance

abuse disorders (1) (0)

Individuals with post-traumatic stress

disorder (PTSD) (1) (0)

Veterans (1) (0)

Active duty military (1) (0)

Members of military families (1) (0)

Individuals with traumatic brain injury (TBI) (1) (0)

Lesbian, gay, bisexual, transgender, or

questioning clients (LGBTQ) (1) (0)

Forensic clients (referred from the court/

judicial system) (1) (0)

Specially-designed mental health treatment program or

group exclusively for any other type of client

(SPECIFY) [specify] END WITH // (1) (0)

(d) DON’T KNOW

(r) REFUSED

A11 Which of these services are offered at this facility, at this location?

INTERVIEWER: For DEFINITIONS OF THESE SERVICES CLICK HERE

YES NO

Consumer-run (peer support) services (1) (0)

Psychiatric emergency walk-in services (1) (0)

Telemedicine therapy (1) (0)

(d) DON’T KNOW

(r) REFUSED

A12 Does this facility offer mental health services for the hearing-impaired?

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

A13 Does this facility provide mental health treatment services in a language other than English at this location?

<1> YES

<0> No, only English [goto a14]

<d> DON’T KNOW [goto a14]

<r> REFUSED [goto a14]

A13a In what other languages do staff provide mental health treatment services at this facility? Do not count languages provided only by on-call interpreters.

<1> Hopi

<2> Lakota

<3> Navajo

<4> Ojibwa

<5> Yupik

<6> Other Native American Indian or

Alaska Native language (Specify) [specify]

<7> Arabic

<8> Any Chinese language

<9> Creole

<10> French

<11> German

<12> Greek

<13> Hmong

<14> Italian

<15> Japanese

<16> Korean

<17> Polish

<18> Portuguese

<19> Russian

<20> Spanish

<21> Tagalog

<22> Vietnamese

<23> Any other language (SPECIFY) [specify] END WITH //

<d> DON’T KNOW

<r> REFUSED

A14 Does this facility offer treatment at no charge to clients who cannot afford to pay?

<1> YES

<0> NO [goto a15]

<d> DON’T KNOW [goto a15]

<r> REFUSED [goto a15]

A14a Do you want the availability of free care for eligible clients published in SAMHSA’s online Mental Health Facility Locator?

PROBE IF NECESSARY: The Locator will inform potential clients to call the facility for information on eligibility.

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

A15 Does this facility use a sliding fee scale?

<1> YES

<0> NO [goto a16]

<d> DON’T KNOW [goto a16]

<r> REFUSED [goto a16]

A15a Do you want the availability of a sliding fee scale published in SAMHSA’s online Mental Health Facility Locator?

PROBE IF NECESSARY: The Locator will explain that sliding fee scales are based on income and other factors.

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

A16 Which of the following types of client payments or insurance are accepted by this facility for mental health treatment services?

YES NO

Medicaid (1) (0)

Medicare (1) (0)

State-financed health insurance plan other

than Medicaid (1) (0)

Federal military insurance

PROBE IF NECESSARY: Insurance such as

TRICARE) (1) (0)

Cash or self-payment

PROBE IF NECESSARY: This includes payments

made out-of-pocket (1) (0)

Private health insurance (1) (0)

IHS/638 contract care funds (1) (0)

(d) DON’T KNOW

(r) REFUSED

A17 What telephone number(s) should a potential client call to schedule a mental health intake appointment at this facility?

INTERVIEWER: IF R TELLS YOU THE INTAKE NUMBER IS THE SAME AS THE NUMBER YOU CALLED, YOU MUST CONFIRM THAT NUMBER. IT IS FILLED AT THE END OF RESPONSE NUMBER 3 FOR THIS PURPOSE. YOU CANNOT ASSUME R KNOWS WHICH NUMBER YOU CALLED TO REACH THEM.

<1> TO RECORD INTAKE PHONE NUMBER(S)

<2> DOES NOT APPLY

<3> SAME NUMBER YOU JUST CALLED [fill adialphone]

<4> SAME NUMBER YOU JUST CALLED [fill adialphone] PLUS ANOTHER NUMBER

ENTER NUMERIC PHONE NUMBER (OPTIONAL): @phn

ENTER EXTENSION (OPTIONAL) @ext

ENTER NUMERIC PHONE NUMBER (OPTIONAL): @phn2

ENTER EXTENSION (OPTIONAL) @ext2

OR

ENTER ALPHA PHONE NUMBER (OPTIONAL): @ac3 @phn3

ENTER EXTENSION (OPTIONAL) @ext3

ENTER ALPHA PHONE NUMBER (OPTIONAL): @ac4 @phn4

ENTER EXTENSION (OPTIONAL) @ext4

<d> DON’T KNOW

<r> REFUSED

A18 Information about facility characteristics and services offered can be published in SAMHSA’s online Mental Health Facility Locator. Does this facility want to be listed in the Locator?

PROBE IF NECESSARY: The Mental Health Facility Locator can be

found at: http://store.samhsa.gov/MHLocator

<1> YES

<0> NO

<d> DON’T KNOW

<r> REFUSED

A19 Does this facility have a website or web page with information about the facility’s mental health treatment programs?

<1> YES

<0> NO [goto a20]

<d> DON’T KNOW [goto a20]

<r> REFUSED [goto a20]

A19a What is this facility’s website address?

Please tell me the address exactly as it should be entered in order to access your site.

<1> RECORD

<d> DON’T KNOW

<r> REFUSED

A20 Does this facility have a National Provider Identifier (NPI) number?

INTERVIEWER: EXCLUDE THE NPI NUMBERS OF INDIVIDUAL PRACTITIONERS AND OF GROUPS OF PRACTITIONERS.

<1> YES

<0> NO [goto b1]

<d> DON’T KNOW [goto b1]

<r> REFUSED [goto b1]

A20a What is the NPI number for this facility?

INTERVIEWER: IF THE FACILITY HAS MORE THAN ONE NPI NUMBER,

RECORD ONLY THE PRIMARY NUMBER.

<1> RECORD NPI NUMBER

<d> DON’T KNOW

<r> REFUSED

B1 ENTER RESPONDENT’S NAME. IF UNKNOWN, ASK.

PLEDGE TO RESPONDENTS

The information you provide will be protected to the fullest extent allowable under Section 501(n) of the Public Health Service Act (42 USC 290aa(n)). This law permits the public release of identifiable information about an establishment only with the consent of that establishment and limits the use of the information to the purposes for which it was supplied. With the explicit consent of eligible treatment facilities, information provided in response to survey questions marked with an asterisk will be published in SAMHSA’s National Directory of Mental Health Treatment Facilities and the Mental Health Treatment Facility Locator. Responses to non-asterisked questions will be published only in statistical summaries so that individual treatment facilities cannot be identified.

Public Burden Statement: 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 0930-0119. Public reporting burden for this collection of information is estimated to average 25 minutes per respondent, per year, 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 this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 8-1099, Rockville, Maryland 20857.

31