Form Locator Survey Que Locator Survey Que Locator Survey Questionnaire

Attachment A.1— 2017 N-MHSS-Locator Survey Paper Questionnaire (also for Between-Survey Update)

U.S. Department of Health and Human Services

OMB No. 0930-xxxx
APPROVAL EXPIRES: XX/XX/20XX
See OMB burden statement on last page

2017 National Mental Health Services
Survey
(N-MHSS)
April 28, 2017
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

i Prepared by Mathematica Policy Research

PLEASE READ THIS ENTIRE PAGE BEFORE
COMPLETING THE QUESTIONNAIRE
Would you prefer to complete this questionnaire online? See the green flyer enclosed in your
questionnaire packet for the Internet address and your unique User ID and Password. You can log
on and off the survey 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


All 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.



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: https://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 any questions or need additional blank forms, contact:

MATHEMATICA POLICY RESEARCH
1-866-778-9752
[email protected]
IMPORTANT INFORMATION
* Asterisked questions. Information from asterisked (*) questions is published in SAMHSA’s online
Behavioral Health Treatment Services Locator, found at https://findtreatment.samhsa.gov, unless you
designate otherwise in question C1, page 6, of this questionnaire.
Mapping feature in online 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 online 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.

ii

*A4.

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.

1
2

Does this treatment facility, at this location,
offer:
3
4

YES NO
1. Mental health intake ........................

1



0



2. Mental health diagnostic evaluation ....

1



0



3. Mental health information and/or
referral (also includes emergency
programs that provide services in
person or by telephone)...................

1



0



*4. Mental health treatment ...................
(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)

1

5. Substance abuse treatment.............

1



0



6. Administrative services for mental
health treatment facilities .................

1



0



0

*A3.

 Yes
 No

6

8
0

9



10

11

 Psychiatric hospital
 Separate inpatient psychiatric unit
of a general hospital (consider this
psychiatric unit as the relevant
“facility” for the purpose of this
survey)
SKIP
TO
 Residential treatment center for children
A7
 Residential treatment center for adults
(NEXT
PAGE)
 Other type of residential treatment
facility
 Veterans Administration medical
center (VAMC) or other VA health
care facility
 Community mental health center (CMHC)
 Partial hospitalization/day treatment facility
 Outpatient mental health facility
 Multi-setting mental health facility (nonhospital residential plus either outpatient
and/or partial hospitalization/day treatment)
 Other (Specify:
_________________________________)

A5.

Is this facility a solo or a small group practice?
1

Did you answer “yes” to mental health
treatment in question A1 above (option 4)?
1

5

7



For definitions of facility types, go to:
https://info.nmhss.org

MARK ONE ONLY

MARK “YES” OR “NO” FOR EACH

A2.

Which ONE category BEST describes this
facility, at this location?

0

A5a.



MARK “YES” OR “NO” FOR EACH

YES NO
1. 24-hour hospital inpatient ................

1



0



2. 24-hour residential ...........................

1



0



3. Partial hospitalization/
day treatment ...................................

1



0



4. Outpatient ........................................

1



0



1
0

A6.

SKIP TO A6 (BELOW)

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

SKIP TO C3 (PAGE 6)

Mental health treatment is provided in which of
the following service settings at this facility, at
this location?

 Yes
 No

Do not count the licenses or credentials of
individual practitioners.
 Yes
 No

SKIP TO C3 (PAGE 6)

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 do not receive grants, but have met the
requirements to receive grants under Section
330 according to the U.S. Department of Health
and Human Services.



For a complete definition of a FQHC, go to:
https://info.nmhss.org

1
0
d

 Yes
 No
 Don’t know
1

A7.

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

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

MARK ONE ONLY
1
2

3

*A9.

Which of these mental health treatment
approaches are offered at this facility, at this
location?


 Substance abuse
treatment
SKIP TO C3 (PAGE 6)
 Mix of mental health and substance abuse
treatment (neither is primary)

1

 Individual psychotherapy

2

 Couples/family therapy

3

 Group therapy

4

 Cognitive behavioral therapy

4

 General health care

5

 Dialectical behavior therapy

5

 Other service focus (Specify:

6

 Behavior modification

7

 Integrated dual disorders treatment

8

 Trauma therapy

9

 Activity therapy

Is this facility a jail, prison, or detention center
that provides treatment exclusively for
incarcerated persons or juvenile detainees?
1

 Yes

0

 No

SKIP TO C3 (PAGE 6)

10

 Electroconvulsive therapy

11

 Telemedicine therapy

12

 Psychotropic medication

13

 Other (Specify:

Is this facility operated by:

_________________________________)

MARK ONE ONLY
14

*A9a.

1

 A private for-profit organization

2

 A private non-profit organization

3

 A public agency or department

SKIP TO
A10 (TOP
OF NEXT
COLUMN)

Which public agency or department?
MARK ONE ONLY
1
2

3

 State mental health authority (SMHA)
 Other state government agency or
department (e.g., Department of Health)
 Regional/district authority or county, local, or
municipal government

4

 Tribal government

5

 Indian Health Service

6

 Department of Veterans Affairs

7

 Other (Specify:
________________________________ )

2

For definitions of treatment approaches, go to:
https://info.nmhss.org

MARK ALL THAT APPLY

 Mental health treatment

________________________________ )
A8.

*A10.

 None of these mental health treatment
approaches are offered

*A11.

Which of these services and practices are
offered at this facility, at this location?


*A12.

What age groups are accepted for treatment
at this facility?
MARK “YES” OR “NO” FOR EACH

For definitions, go to: https://info.nmhss.org

YES NO
MARK ALL THAT APPLY
1

 Assertive community treatment (ACT)

2

 Intensive case management (ICM)

3

 Case management (CM)

4

 Court-ordered outpatient treatment

5

 Chronic disease/illness management (CDM)

6

 Illness management and recovery (IMR)

7

 Integrated primary care services

8

 Diet and exercise counseling

9

 Family psychoeducation

10

 Education services

11

 Housing services

12

 Supported housing

13

 Psychosocial rehabilitation services

14

 Vocational rehabilitation services

15

 Supported employment

*A13.

1. Children (12 or younger) .................

1



0



2. Adolescents (13-17) ........................

1



0



3. Young adults (18-25) .......................

1



0



4. Adults (26-64) ..................................

1



0



5. Seniors (65 or older) ........................

1



0



Does this facility offer a mental health treatment
program or group that is dedicated or designed
exclusively for clients in any of the following
categories?


If this facility treats clients in any of these
categories, but does not have a specifically
tailored program or group for them, DO NOT
mark the box for that category.

MARK ALL THAT APPLY
1

2
3

 Children/adolescents with serious emotional
disturbance (SED)
 Transitional age young adults
 Persons 18 and older with serious mental
illness (SMI)

16

 Therapeutic foster care

4

 Seniors or older adults

17

 Legal advocacy

5

 Persons with Alzheimer’s or dementia

18

 Psychiatric emergency walk-in services

6

19

 Suicide prevention services

20

 Consumer-run (peer support) services

7
8

21

 Screening for tobacco use

22

 Smoking/tobacco cessation counseling

23

 Nicotine replacement therapy

24

25

 Non-nicotine smoking/tobacco cessation
medications (by prescription)
 Other (Specify:

9

 Persons with a diagnosis of post-traumatic
stress disorder (PTSD)
 Persons who have experienced trauma
(excluding persons with a PTSD diagnosis)
 Persons with traumatic brain injury (TBI)

11

 Veterans

12

 Active duty military

13

 Members of military families

14

 None of these services and practices are
offered

 Persons with eating disorders

10

________________________________ )
26

 Persons with co-occurring mental and
substance use disorders

15

 Lesbian, gay, bisexual, or transgender
clients (LGBT)
 Forensic clients (referred from the court/
judicial system)

16

 Persons with HIV or AIDS

17

 Other special program or group (Specify:
_________________________________)

18

 No dedicated or exclusively designed
programs or groups are offered

3

*A14.

Does this facility offer a crisis intervention
team that handles acute mental health issues
at this facility and/or off-site?
1
0

*A15.

*A16b. In what other languages do staff provide mental
health treatment services at this facility?


 Yes
 No

MARK ALL THAT APPLY

American Indian or Alaska Native:

Does this facility provide mental health
treatment services in sign language at this
location for the deaf and hard of hearing (for
example, American Sign Language, Signed
English, or Cued Speech)?

1
2
3

 Mark “yes” if either staff or an on-call interpreter

6

provides this service.
1 
Yes
0 
No

0

 Yes
 No, only English

25

 Any other language (Specify:

11

SKIP TO A17
(NEXT COLUMN)

12

14

MARK ONE ONLY

2

 On-call interpreter (in person or
by phone) brought in
SKIP TO A17
when needed
 BOTH staff and on-call interpreter

*A17.

1
0

A16a2.

4

 Yes
 No

SKIP TO A16b
(TOP OF NEXT COLUMN)

Do staff at this facility provide mental health
treatment services in any other languages?
1

 Yes

SKIP TO A16b
(TOP OF NEXT COLUMN)

0

 No

SKIP TO A17
(NEXT COLUMN)

16
17
18
19
20
21
22
23
24











Hmong
Italian
Japanese
Korean
Polish
Portuguese
Russian
Tagalog
Vietnamese

Which of the following statements BEST
describes this facility’s smoking policy for
clients?
MARK ONE ONLY
1

*A16a1. Do staff provide mental health treatment
services in Spanish at this facility?

Arabic
Any Chinese language
Creole
Farsi
French
German
Greek
Hebrew
Hindi

_______________________________ )

 Staff who speak a language other than
English

(NEXT COLUMN)

3

 Other American Indian or Alaska Native
Language (Specify:

15

9
10

At this facility, who provides mental health
treatment services in a language other than
English?
1

5

 Ojibwa
 Yupik











8

13

A16a.

4

Other Languages:

Does this facility provide mental health
treatment services in a language other than
English at this location?
1

 Hopi
 Lakota
 Navajo

_______________________________ )

7

*A16.

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

 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

*A18.

Does this facility use a sliding fee scale?


1
0

Not applicable to Veterans Administration
facilities.
 Yes
 No

*A19.



Not applicable to Veterans Administration
facilities.



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

0

 No

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

1
0

Not applicable to Veterans Administration
facilities.
 Yes
 No

SKIP TO A20
(TOP OF NEXT COLUMN)

A19a. Do you want the availability of treatment at no
charge for eligible clients published in
SAMHSA’s online Behavioral Health Treatment
Services Locator?


Not applicable to Veterans Administration
facilities.



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

1

 Yes

0

 No

Which of the following types of client payments,
insurance, or funding are accepted by this
facility for mental health treatment services?
MARK “YES,” “NO” OR “DON’T KNOW” FOR EACH

YES

SKIP TO A19 (BELOW)

A18a. Do you want the availability of a sliding fee
scale published in SAMHSA’s online Behavioral
Health Treatment Services Locator?

1

*A20.

DON’T
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/Tribal/Urban (ITU)
funds ......................................

1



0



d



17. Other .....................................

1



0



d



(Specify:______________________________ )

5

A21.

From which of these agencies or organizations
does this facility have licensing, certification, or
accreditation?


C1a.

Do not include personal-level credentials or
general business licenses such as a food service
license.
MARK “YES,” “NO” OR “DON’T KNOW” FOR EACH

YES

NO



DON’T
KNOW

1.

State mental health authority......

1



0



d



2.

State substance abuse agency ..

1



0



d



1
0

 Yes
 No

State department of health .........

1



0



d



4.

State or local Department of
Family and Children’s Services ...

1



0



d



5.

Hospital licensing authority .........

1



0



d



6.

The Joint Commission ................

1



0



d



7.

Commission on Accreditation
of Rehabilitation Facilities
(CARF) .......................................

1



0



d



8.

Council on Accreditation (COA) .

1



0



d





9.

Centers for Medicare and
Medicaid Services ......................

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

1



0



d





10. Other national organization, or
federal, state, or local agency ....

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

1



0



d



C2.

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

1. (______) ________ - ____________ ext._____
2. (______) ________ - ____________ ext._____

SECTION C: GENERAL INFORMATION
If eligible, does this facility want to be listed in
SAMHSA’s online Behavioral Health Treatment
Services Locator?

1
0

The Locator can be found at:
https://findtreatment.samhsa.gov
 Yes
 No

Does this facility have a website or web page
with information about the facility’s mental
health treatment program(s)?
1
0

INTAKE TELEPHONE NUMBER(S):

C1.

Information to be shared would be: facility
name, location address, telephone number, and
website address.

3.

*C2a.

GO TO C1a (TOP OF NEXT COLUMN)
GO TO C2 (NEXT COLUMN)

 Yes
 No

SKIP TO C3 (BELOW)

What is this facility’s website address?

Website: _______________________________

(Specify: _______________________________ )

*A22.

To increase public awareness of behavioral
health services, SAMHSA may be sharing
facility contact information with large
commercially available Internet search engines,
such as Google, Bing, Yahoo!, etc. Do you want
your facility information shared on these
Internet search engines?

C3.

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.

5

 Other (Specify: _______________________)

2

 Mrs.

3

 Mr.

4

 Dr.

Name: ________________________________________
Title: _________________________________________
Phone Number: (_____) _______ - _______ Ext. ______
Fax Number: (_____) _______ - _______
Email Address: _________________________________
Facility Email Address: ___________________________

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:
MATHEMATICA POLICY RESEARCH
ATTN: RECEIPT CONTROL - Project 50345_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 may be published in SAMHSA’s online
Behavioral Health Treatment Services Locator, the National Directory of Mental Health Treatment Facilities, and other publically available listings. Responses to non-asterisked questions will
be published with no direct link to individual treatment facilities.
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-xxxx. 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, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland 20857.

6