Form 2014 N-MHSS (Full- 2014 N-MHSS (Full- 2014 N-MHSS (Full-Scale) Paper Questionnaire

Attachment A.1 – (2014 N-MHSS (Full-Scale) Paper Questionnaire)

U.S. Department of Health and Human Services OMB No. 0930-XXXX

APPROVAL EXPIRES: XX/XX/20XX

See OMB burden statement on last page

2014 National Mental Health Services Survey

(N-MHSS)

April 30, 2014

Substance Abuse and Mental Health Services Administration (SAMHSA)

PLEASE REVIEW THE FACILITY INFORMATION PRINTED ABOVE.

CROSS OUT ERRORS AND ENTER CORRECT OR MISSING INFORMATION.

CHECK ONE

• Information is complete and correct, no changes needed

• All missing or incorrect information has been corrected

Would you prefer to complete this questionnaire online? See the blue flyer enclosed in your questionnaire packet for the Internet address and your unique user ID and password. You can log on and off the website as often as needed to complete the questionnaire. When you log on again, the program will take you to the next unanswered question. If you need additional help or information, call the N-MHSS helpline at 1-866-778-9752.

INSTRUCTIONS

• Most of the questions in this survey ask about “this facility.” By “this facility” we mean the specific treatment facility or program whose name and location are printed on the front cover. If you have any questions about how the term “this facility” applies to your facility, please call 1-866-778-9752.

• Please answer ONLY for the specific facility or program whose name and location are printed on the front cover, unless otherwise specified in the questionnaire.

• If this is a separate inpatient psychiatric unit of a general hospital, consider the psychiatric unit as the relevant “facility” for the purpose of this survey.

• For additional information about the survey and definitions for some of the terms, please visit our website at: http://info.nmhss.org.

• Return the completed questionnaire in the envelope provided, or fax it to 1-609-799-0005. (Please reference “N-MHSS” on your fax.)

Please keep a copy of your completed questionnaire for your records.

• If you have questions or need additional blank forms, contact:

mathematica policy research

1-866-778-9752

N

IMPORTANT INFORMATION

• * Asterisked Questions. Information from asterisked (_*) questions is published in SAMHSA’s online Behavioral Health Treatment Services Locator, found at http://findtreatment.samhsa.gov, unless you designate otherwise in question C1, page 11, of this questionnaire.

• Mapping Feature in Locator. Complete and accurate name and address information is needed for SAMHSA’s online Behavioral Health Treatment Services Locator so it can correctly map the facility’s location.

• Eligibility for Locator. Only facilities that provide mental health treatment and complete this questionnaire are eligible to be listed in the online Behavioral Health Treatment Services Locator. If you have any questions regarding eligibility, please contact the N-MHSS helpline at 1‑866‑778-9752.

[email protected]

prepared by mathematica policy research

prepared by mathematica policy research

SECTION A: FACILITY

CHARACTERISTICS

Section A asks about characteristics of individual facilities and should be completed for this facility only, that is, the treatment facility or program at the location listed on the front cover.

A1. Does this facility, at this location, offer:

MARK “YES” OR “NO” FOR EACH

YES NO

1. Mental health intake 1  0 

2. Mental health diagnostic evaluation 1  0 

3. Mental health information and 1  0 

referral (also includes emergency programs that provide services in person or by telephone)

*4. Mental health treatment 1  0 

(interventions such as therapy or

psychotropic medication that treat a

person’s mental health problem or

condition, reduce symptoms, and

improve behavioral functioning and

outcomes)

5. Substance abuse treatment 1  0 

6. Administrative services 1  0 

A2. Did you answer “yes” to mental health treatment in question A1 above (option 4)?

1  Yes

0  No SKIP TO C1 (PAGE 11)

*A3. What levels of care are offered at this facility, at this location, for mental health treatment?

MARK “YES” OR “NO” FOR EACH

YES NO

1. 24-hour hospital inpatient care 1  0 

2. 24-hour residential care 1  0 

3. Less than 24-hour partial hospitalization 1  0 

4. Less than 24-hour outpatient care 1  0 

*A4. Which ONE category best describes this facility, at this location?

• For definitions of facility types, log on to: http://info.nmhss.org

MARK ONE ONLY

1  Psychiatric hospital

2  Separate inpatient psychiatric

unit of a general hospital

(consider this psychiatric unit

as the relevant “facility” for the

purpose of this survey)

3  Residential treatment center for

children only

4  Residential treatment center for

adults only

5  Other residential treatment

setting

6  Veterans Administration medical

center (VAMC)/facility

7  Community mental health

center

8  Outpatient mental health facility

9  Multi-setting mental health facility (non-hospital

residential plus outpatient or partial hospitalization)

10  Other (Specify:

)

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

1  Yes

0  No SKIP TO A6 (BELOW)

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

• Do not count the licenses or credentials of individual practitioners.

1  Yes

0  No SKIP TO C4 (PAGE 11)

A6. Is this facility a Federally Qualified Health Center (FQHC)?

• FQHCs include: (1) all organizations that receive grants under Section 330 of the Public Health Service Act; and (2) other organizations that have not received grants to date, but have met the requirements to receive grants under Section 330 according to U.S. Department of Health and Human Services.

1  Yes

0  No

A7. What is the primary treatment focus of this facility, at this location?

• Separate psychiatric units in a general hospital should answer for just their unit and NOT for the entire hospital

MARK ONE ONLY

1  Mental health treatment

2  Substance abuse

treatment SKIP TO C4 (PAGE 11)

3  Mix of mental health and substance abuse

treatment (neither is primary)

4  General health care

5  Other service focus (Specify:

)

A8. Is this facility a jail, prison, or detention center that provides treatment exclusively for incarcerated persons or juvenile detainees?

1  Yes SKIP TO C4 (PAGE 11)

0  No

*A9. Is this facility operated by:

MARK ONE ONLY

1  A private for-profit organization

2  A private non-profit organization

3  A public agency or department

*A9a. Which public agency or department?

MARK ONE ONLY

1  State mental health authority (SMHA)

2  Other state government agency or

department (e.g., Department of Health)

3  Regional/district authority or local, county,

or municipal government

4  Tribal government

5  Department of Veterans Affairs

6  Indian Health Service

7  Other (Specify:

)

A10. Is this facility affiliated with a religious organization?

1  Yes

0  No

*A11. Which of these mental health treatment approaches are offered at this facility, at this location?

• For definitions of treatment approaches, log on to: http://info.nmhss.org

MARK “YES” OR “NO” FOR EACH

YES NO

1. Activity therapy 1  0 

2. Behavior modification 1  0 

3. Cognitive/behavioral therapy 1  0 

4. Couples/family therapy 1  0 

5. Electroconvulsive therapy 1  0 

6. Group therapy 1  0 

7. Individual psychotherapy 1  0 

8. Integrated dual disorders treatment 1  0 

9. Psychotropic medication 1  0 

10. Telemedicine therapy 1  0 

11. Other (Specify: 1  0 

)

*A12. Which of these supportive services and practices are offered at this facility, at this location?

• For definitions of supportive practices, log on to:  http://info.nmhss.org

MARK “YES” OR “NO” FOR EACH

YES NO

1. Assertive community treatment 1  0 

2. Case management 1  0 

3. Chronic disease/illness management (CDM) 1  0 

4. Consumer-run (peer support) services 1  0 

5. Court-ordered outpatient treatment 1  0 

6. Education services 1  0 

7. Family psychoeducation 1  0 

8. Housing services 1  0 

9. Illness management and recovery (IMR) 1  0 

10. Legal advocacy 1  0 

11. Nicotine replacement therapy 1  0 

12. Non-nicotine smoking/tobacco cessation

medications (by prescription) 1  0 

13. Psychiatric emergency walk-in services 1  0 

14. Psychosocial rehabilitation services 1  0 

15. Screening for tobacco use 1  0 

16. Suicide prevention services 1  0 

17. Supported employment 1  0 

18. Supported housing 1  0 

19. Therapeutic foster care 1  0 

20. Tobacco cessation counseling 1  0 

21. Vocational rehabilitation services 1  0 

22. Other 1  0 

(Specify: )

*A13. What age groups are accepted for treatment at this facility?

MARK “YES” OR “NO” FOR EACH

YES NO

1. Children (17 or younger) 1  0 

2. Young adults (18-25) 1  0 

3. Adults (26-64) 1  0 

4. Seniors (65 or older) 1  0 

*A14. Does this facility offer a mental health treatment program or group designed exclusively for:

• If you treat these clients for mental health, but do not have a specifically tailored program or group for them, check "NO."

MARK “YES” OR “NO” FOR EACH

YES NO

1. Children with serious emotional

disturbance (SED) 1  0 

2. Adults with serious mental illness (SMI) 1  0 

3. Seniors or older adults 1  0 

4. Persons with Alzheimer’s or dementia 1  0 

5. Persons with co-occurring mental

and substance use disorders 1  0 

6. Persons with eating disorders 1  0 

7. Persons with HIV or AIDS 1  0 

8. Persons with post-traumatic stress

disorder (PTSD) 1  0 

9. Veterans 1  0 

10. Active duty military 1  0 

11. Members of military families 1  0 

12. Persons with traumatic brain injury (TBI) 1  0 

13. Lesbian, gay, bisexual, or transgender

clients (LGBT) 1  0 

14. Forensic clients (referred from the court/

judicial system) 1  0 

15. Other special program (Specify: 1  0 

)

*A15. Does this facility offer a crisis intervention team that handles acute mental health issues at this facility and/or off-site?

1  Yes

0  No

*A16. Does this facility offer mental health treatment services for the hearing-impaired?

1  Yes

0  No

*A17. Does this facility provide mental health treatment services in a language other than English at this location?

1  Yes

0  No, only English SKIP TO A18 (NEXT COLUMN)

*A17a. Do staff provide mental health treatment services in Spanish at this facility?

1  Yes

0  No

A17b. Do staff at this facility provide mental health treatment services in any other languages?

1  Yes

0  No SKIP TO A18 (NEXT COLUMN)

*A17c. In what other languages do staff provide mental health treatment services at this facility?

• Do not count languages provided only by on-call interpreters.

MARK ALL THAT APPLY

American Indian or Alaska Native:

1  Hopi 4  Ojibwa

2  Lakota 5  Yupik

3  Navajo

6  Other Native American Indian or Alaska Native

language

(Specify: _____________________________)

Other Languages:

7  Arabic 15  Japanese

8  Any Chinese Language 16  Korean

9  Creole 17  Polish

10  French 18  Portuguese

11  German 19  Russian

12  Greek 20  Tagalog

13  Hmong 21  Vietnamese

14  Italian

22  Any other language (Specify:

____________________________________)

A18. Which of these quality assurance practices are part of this facility’s standard operating procedures?

MARK “YES” OR “NO” FOR EACH

YES NO

1. Monitoring continuing education

requirements for professional staff 1  0 

2. Regularly scheduled case review with

a supervisor 1  0 

3. Regularly scheduled case review by an

appointed quality review committee 1  0 

4. Client/patient outcome follow-up after

discharge 1  0 

5. Periodic utilization review 1  0 

6. Periodic client/patient satisfaction surveys 1  0 

*A19. Which statement(s) below BEST describe(s) this facility’s smoking policy for clients?

MARK ONE ONLY

1  Not permitted to smoke anywhere outside or within any building

2  Permitted in designated outdoor area(s)

3  Permitted anywhere outside

4  Permitted in designated indoor area(s)

5  Permitted anywhere inside

6  Permitted anywhere without restriction

A20. In the 12-month period beginning May 1, 2013, and ending April 30, 2014, have staff at this facility used seclusion or restraint with clients?

1  Yes

0  No SKIP TO A21 (PAGE 5)

A20a. In the 12-month period beginning May 1, 2013, and ending April 30, 2014, has your facility adopted any initiatives to reduce the use of seclusion or restraint?

1  Yes

0  No

A21. For each of the following functions, please indicate if staff members routinely use computer or electronic resources, paper only, or a combination of both to complete the function.

Function	Computer/ Electronic Only	Paper Only	Both Electronic and Paper	N/A
1. Intake	1 	2 	3 	0 
2. Scheduling appointments	1 	2 	3 	0 
3. Assessment/ evaluation	1 	2 	3 	0 
4. Treatment plan	1 	2 	3 	0 
5. Discharge	1 	2 	3 	0 
6. Referrals	1 	2 	3 	0 
7. Issue/receive lab results	1 	2 	3 	0 
8. Billing	1 	2 	3 	0 
9. Client progress monitoring	1 	2 	3 	0 
10. Prescribing/dispensing medication	1 	2 	3 	0 
11. Checking medication interactions	1 	2 	3 	0 
12. Health records	1 	2 	3 	0 
13. Collaboration with a client’s other providers (such as primary care provider)	1 	2 	3 	0 
14. Client or family satisfaction surveys	1 	2 	3 	0 

*A22. Does this facility use a sliding fee scale?

1  Yes

0  No SKIP TO A23 (NEXT COLUMN)

A22a. Do you want the availability of a sliding fee scale published in SAMHSA’s online Behavioral Health Treatment Services Locator?

• The Locator will explain that sliding fee scales are based on income and other factors.

1  Yes

0  No

*A23. Does this facility offer treatment at no charge to clients who cannot afford to pay?

1  Yes

0  No SKIP TO A24 (BELOW)

A23a. Do you want the availability of free care for eligible clients published in SAMHSA’s online Behavioral Health Treatment Services Locator?

• The Locator will inform potential clients to call the facility for information on eligibility.

1  Yes

0  No

*A24. Which of the following types of client payments, insurance, or funding are accepted by this facility for mental health treatment services?

MARK “YES” OR “NO” FOR EACH

DON’T

YES NO KNOW

1. Cash or self-payment 1  0  d 

2. Private health insurance 1  0  d 

3. Medicare 1  0  d 

4. Medicaid 1  0  d 

5. State-financed health insurance plan other than Medicaid 1  0  d 

6. State mental health agency (or equivalent) funds 1  0  d 

7. State welfare or child and family services agency funds 1  0  d 

8. State corrections or juvenile justice agency funds 1  0  d 

9. State education agency funds 1  0  d 

10. Other state government funds 1  0  d 

11. County or local government funds 1  0  d 

12. Community Service Block Grants 1  0  d 

13. Community Mental Health Block Grants 1  0  d 

14. Federal military insurance (such as TRICARE) 1  0  d 

15. U.S. Department of Veterans Affairs funds 1  0  d 

16. IHS/638 contract care funds 1  0  d 

17. Other (Specify: 1  0  d 

_____________________________)

A25. From which of these organizations does this facility have licensing, certification, or accreditation?

• Do not include personal-level credentials or general business licenses such as a food service license.

MARK “YES” OR “NO” FOR EACH

YES NO

1. State mental health authority 1  0 

2. State substance abuse agency 1  0 

3. State department of health 1  0 

4. Hospital licensing authority 1  0 

5. The Joint Commission (JC) 1  0 

6. Commission on Accreditation of

Rehabilitation Facilities (CARF) 1  0 

7. Council on Accreditation (COA) 1  0 

8. Department of Family and

Children’s Services 1  0 

9. Medicare 1  0 

10. Medicaid 1  0 

11. Other national, state, or local

organization (Specify: 1  0 

)

*A26. What telephone number(s) should a potential client call to schedule an intake appointment?

INTAKE TELEPHONE NUMBER(S):

1. (____) ______ - ___________ ext.______

2. (____) ______ - ___________ ext.______

SECTION B: CLIENT/PATIENT COUNT INFORMATION

Questions B3 – B8 ask about the number of clients/patients treated at this facility on specific dates.

Please look carefully at the dates specified, as questions will ask for either a single day count, a one‑month count, or a 12-month count.

Include ALL clients/patients receiving mental health treatment in your counts, even if a mental health disorder is a secondary diagnosis or has not yet been formally determined.

B1. Although reporting for only the clients/patients treated at this facility is preferred, we realize that may not be possible. Will the client/patient counts reported in this questionnaire include…

MARK ONE ONLY

1 ¨ Only this facility SKIP TO B3 (PAGE 7)

2 ¨ This facility plus others SKIP TO B2 (BELOW)

3 ¨ Another facility in the organization will report

client counts for this facility

B1a. Please record the name and phone number of the facility that will report your client counts.

Facility name:

Telephone: (_____) - ______-

After recording the facility name and telephone number in B1a SKIP TO C1

(PAGE 11)

B2. How many facilities will be included in the reported client counts?

1

THIS FACILITY

+ ADDITIONAL FACILITIES

= TOTAL FACILITIES

On page 12 of this questionnaire, list the name and location address of each facility included in your client counts. If you prefer, we will contact you for a list of the other facilities included in your client counts.

CONTINUE WITH QUESTION B3 (TOP OF NEXT PAGE)

24-HOUR HOSPITAL INPATIENT COUNTS

B3. On April 30, 2014, did any patients receive 24‑hour hospital inpatient mental health treatment at this facility, at this location?

1  Yes GO TO B3a (TOP OF NEXT COLUMN)

0  No SKIP TO B4 (PAGE 8)

B3a. On April 30, 2014, how many patients received 24‑hour hospital inpatient mental health treatment at this facility?

• Do NOT count family members, friends, or other non‑treatment patients

HOSPITAL INPATIENTS TOTAL BOX

CONTINUE WITH QUESTION B3b (BELOW)

B3b. For each category below, please provide a breakdown of the Hospital Inpatients reported in the B3a TOTAL BOX above. Use either numbers OR percents, whichever is more convenient.

• If numbers are used—each category total should equal the number reported in the B3a TOTAL BOX above

• If percents are used—each category total should equal 100%

	NUMBER	OR	PERCENT
GENDER Male
Female
CATEGORY TOTAL: (Should=B3a or 100%)			100%

AGE 0 – 17
18 – 64
65 and older
CATEGORY TOTAL: (Should=B3a or 100%)			100%

ETHNICITY Hispanic or Latino
Not Hispanic or Latino
Unknown or not collected
CATEGORY TOTAL: (Should=B3a or 100%)			100%

RACE American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or more races
Unknown or not collected
CATEGORY TOTAL: (Should=B3a or 100%)			100%

LEGAL STATUS Voluntary
Involuntary, non-forensic
Involuntary, forensic
CATEGORY TOTAL: (Should=B3a or 100%)			100%

B3c. On April 30, 2014, how many hospital inpatient beds at this facility were specifically designated for providing mental health treatment?

NUMBER OF BEDS

(If none, enter ‘0’)

24-HOUR RESIDENTIAL (NON-HOSPITAL) CLIENT COUNTS

B4. On April 30, 2014, did any clients receive 24-hour residential mental health treatment at this facility, at this location?

1  Yes GO TO B4a (TOP OF NEXT COLUMN)

0  No SKIP TO B5 (PAGE 9)

B4a. On April 30, 2014, how many clients received 24‑hour residential mental health treatment at this facility?

• Do NOT count family members, friends, or other non‑treatment clients

RESIDENTIAL CLIENTS TOTAL BOX

CONTINUE WITH QUESTION B4b (BELOW)

B4b. For each category below, please provide a breakdown of the Residential Clients reported in the B4a TOTAL BOX above. Use either numbers OR percents, whichever is more convenient.

• If numbers are used—each category total should equal the number reported in the B4a TOTAL BOX above

• If percents are used—each category total should equal100%

	NUMBER	OR	PERCENT
GENDER Male
Female
CATEGORY TOTAL: (Should=B4a or 100%)			100%

AGE 0 – 17
18 – 64
65 and older
CATEGORY TOTAL: (Should=B4a or 100%)			100%

ETHNICITY Hispanic or Latino
Not Hispanic or Latino
Unknown or not collected
CATEGORY TOTAL: (Should=B4a or 100%)			100%

RACE American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or more races
Unknown or not collected
CATEGORY TOTAL: (Should=B4a or 100%)			100%

LEGAL STATUS Voluntary
Involuntary, non-forensic
Involuntary, forensic
CATEGORY TOTAL: (Should=B4a or 100%)			100%

B4c. On April 30, 2014, how many residential beds at this facility were specifically designated for providing mental health treatment?

NUMBER OF BEDS

(If none, enter ‘0’)

LESS THAN 24-HOUR OUTPATIENT CLIENT COUNTS

B5. During the month of April 2014, did any clients receive less than 24-hour outpatient mental health treatment at this facility, at this location?

ALSO INCLUDE PARTIAL HOSPITALIZATION CLIENTS ON THIS PAGE.

1  Yes GO TO B5a (TOP OF NEXT COLUMN)

0  No SKIP TO B6 (PAGE 10)

B5a. During the month of April 2014, how many clients received outpatient mental health treatment at this facility?

• ONLY INCLUDE those seen at this facility at least once during the month of April, AND who were still enrolled in treatment on April 30, 2014

• DO NOT count family members, friends, or other non‑treatment clients

OUTPATIENT CLIENTS TOTAL BOX

CONTINUE WITH QUESTION B5b (BELOW)

B5b. For each category below, please provide a breakdown of the Outpatient Clients reported in the B5a TOTAL BOX above. Use either numbers OR percents, whichever is more convenient.

• If numbers are used—each category total should equal the number reported in the B5a TOTAL BOX above

• If percents are used—each category total should equal 100%

	NUMBER	OR	PERCENT
GENDER Male
Female
CATEGORY TOTAL: (Should=B5a or 100%)			100%

AGE 0 – 17
18 – 64
65 and older
CATEGORY TOTAL: (Should=B5a or 100%)			100%

ETHNICITY Hispanic or Latino
Not Hispanic or Latino
Unknown or not collected
CATEGORY TOTAL: (Should=B5a or 100%)			100%

RACE American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or more races
Unknown or not collected
CATEGORY TOTAL: (Should=B5a or 100%)			100%

LEGAL STATUS Voluntary
Involuntary, non-forensic
Involuntary, forensic
CATEGORY TOTAL: (Should=B5a or 100%)			100%

ALL MENTAL HEALTH CARE SETTINGS

Including 24-hour Hospital Inpatient, 24-Hour Residential (non-hospital),

and Less Than 24-Hour Outpatient (including Partial Hospitalization)

B6. On April 30, 2014, approximately what percent of the mental health treatment clients enrolled at this facility had diagnosed co-occurring mental and substance use disorders?

PERCENT WITH CO-OCCURRING DIAGNOSIS

%

(If none, enter ‘0’)

B7. In the 12-month period of May 1, 2013 through April 30, 2014, how many mental health treatment admissions, readmissions, and incoming transfers did this facility have? Exclude returns from unauthorized absence, such as escape, AWOL, or elopement.

• IF DATA FOR THIS TIME PERIOD ARE NOT AVAILABLE: Use the most recent 12-month period for which data are available

• OUTPATIENT CLIENTS: Consider each initiation to a course of treatment as an admission. Count admissions into treatment, not individual treatment visits

• WHEN A MENTAL HEALTH DISORDER IS A SECONDARY DIAGNOSIS: Count all admissions where clients received mental health treatment.

NUMBER OF MENTAL HEALTH TREATMENT ADMISSIONS IN 12‑MONTH PERIOD

(If none, enter ‘0’)

B8. What percent of the admissions reported in question B7 above were military veterans? Please give your best estimate.

PERCENT MILITARY VETERANS

%

(If none, enter ‘0’)

SECTION C: GENERAL INFORMATION

C1. If eligible, does this facility want to be listed in SAMHSA’s online Behavioral Health Treatment Services Locator?

• The Locator can be found at http://findtreatment.samhsa.gov

1  Yes

0  No

C2. Does this facility have a website or web page with information about the facility’s mental health treatment program(s)?

1  Yes

0  No SKIP TO C3 (BELOW)

*C2a. What is this facility’s website address?

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

• Do not enter http:// (for example, enter www.yourfacility.com)

Website: _________________________________

C3. Does this facility have a National Provider Identifier (NPI) number?

• Do not include the NPI numbers of individual practitioners and of groups of practitioners.

1  Yes

0  No SKIP TO C4 (NEXT COLUMN)

C3a. What is the NPI number for this facility?

• If the facility has more than one NPI number, please provide only the primary number.

NPI
	(NPI is a 10-digit numeric ID)

C4. Who was primarily responsible for completing this form? This information will only be used if we need to contact you about your responses. It will not be published.

MARK ONE ONLY

1  Ms.

2  Mrs.

3  Mr.

4  Dr.

5  Other (Specify: )

NAME:

TITLE:

PHONE NUMBER:

(

) -

-

Area Code

Extension

FAX NUMBER:

(

) -

-

Area Code

EMAIL ADDRESS:

FACILITY EMAIL ADDRESS:

A

Complete this section if you reported clients for this facility plus additional facilities, as indicated in Question B2.

For each additional facility, please mark if that facility offers hospital inpatient, residential, and/or outpatient mental health treatment (including partial hospitalization) at that location.

DDITIONAL FACILITIES INCLUDED IN CLIENT COUNTS

FACILITY NAME: ADDRESS: CITY: STATE: ZIP: PHONE: FACILITY EMAIL ADDRESS:			FACILITY NAME: ADDRESS: CITY: STATE: ZIP: PHONE: FACILITY EMAIL ADDRESS:
¨ HOSPITAL INPATIENT	¨ RESIDENTIAL	¨ OUTPATIENT	¨ HOSPITAL INPATIENT	¨ RESIDENTIAL	¨ OUTPATIENT
FACILITY NAME: ADDRESS: CITY: STATE: ZIP: PHONE: FACILITY EMAIL ADDRESS:			FACILITY NAME: ADDRESS: CITY: STATE: ZIP: PHONE: FACILITY EMAIL ADDRESS:
¨ HOSPITAL INPATIENT	¨ RESIDENTIAL	¨ OUTPATIENT	¨ HOSPITAL INPATIENT	¨ RESIDENTIAL	¨ OUTPATIENT
FACILITY NAME: ADDRESS: CITY: STATE: ZIP: PHONE: FACILITY EMAIL ADDRESS:			FACILITY NAME: ADDRESS: CITY: STATE: ZIP: PHONE: FACILITY EMAIL ADDRESS:
¨ HOSPITAL INPATIENT	¨ RESIDENTIAL	¨ OUTPATIENT	¨ HOSPITAL INPATIENT	¨ RESIDENTIAL	¨ OUTPATIENT

If you require additional space, please continue on the next page.

ANY ADDITIONAL COMMENTS

T hank you for your participation. Please return this questionnaire in the envelope provided.

If you no longer have the envelope, please mail this questionnaire to:

MATHEMATICA POLICY RESEARCH

ATTN: RECEIPT CONTROL - Project 06667_1

P.O. Box 2393

Princeton, NJ 08543-2393

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 Behavioral Health Treatment Services 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-XXX. Public reporting burden for this collection of information is estimated to average 45 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 2-1057, Rockville, Maryland 20857.

PREPARED BY MATHEMATICA POLICY RESEARCH