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pdfAttachment A.2— 2018 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
2018 National Mental Health Services
Survey
(N-MHSS)
April 30, 2018
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
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
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: 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 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 12, 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.
SECTION A: FACILITY
CHARACTERISTICS
*A4.
For definitions of facility types, go to:
https://info.nmhss.org
MARK ONE ONLY
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.
Which ONE category BEST describes this
facility, at this location?
2. Mental health diagnostic evaluation...... 1
0
3. Mental health information and/or .......... 1
0
0
*A3.
No
0
0
7
Community mental health center (CMHC)
8
Partial hospitalization/day treatment facility
9
Outpatient mental health facility
Multi-setting mental health facility (nonhospital residential plus either
outpatient and/or partial
hospitalization/day treatment)
Other (Specify:
A5a.
Is this facility a solo or a small group practice?
1
Yes
0
No
SKIP TO A6 (BELOW)
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.
SKIP TO C3 (PAGE 12)
Mental health treatment is provided in which of
the following service settings at this facility, at
this location?
A6.
MARK “YES” OR “NO” FOR EACH
1
Yes
0
No
1. 24-hour hospital inpatient ................................ 1
0
2. 24-hour residential ........................................... 1
0
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
3. Partial hospitalization/
day treatment ................................................... 1
0
4. Outpatient ........................................................ 1
0
SKIP TO C3 (PAGE 12)
Is this facility a Federally Qualified Health Center
(FQHC)?
YES NO
1
Veterans Administration medical center
(VAMC) or other VA health care facility
A5.
Did you answer “yes” to mental health treatment
in question A1 above (option 4)?
SKIP
TO
A7
(NEXT
PAGE)
)
treatment facilities ................................. 1
0
Other type of residential treatment
6
6. Administrative services for mental health
Yes
5
11
5. Substance abuse treatment .................. 1
Residential treatment center for adults
(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
4
10
*4. Mental health treatment ........................ 1
Residential treatment center for
facility
referral (also includes emergency
programs that provide services in
person or by telephone)
A2.
Separate inpatient psychiatric unit of a
children
NO
0
2
3
MARK “YES” OR “NO” FOR EACH
1. Mental health intake .............................. 1
Psychiatric hospital
general hospital (consider this
psychiatric unit as the relevant “facility”
for the purpose of this survey)
Does this treatment facility, at this location, offer:
YES
1
0
d
1
Yes
No
Don’t know
A7.
What is the primary treatment focus of this
facility, at this location?
*A9a. Which public agency or department?
MARK ONE ONLY
Separate psychiatric units in general hospitals
should answer for just their unit and NOT for the
entire hospital.
1
2
MARK ONE ONLY
1
2
3
3
Mental health treatment
Substance abuse
treatment
SKIP TO C3 (PAGE 12)
Mix of mental health and substance abuse
treatment (neither is primary)
4
General health care
5
Other service focus (Specify:
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:
)
)
A10.
A8.
*A9.
Is this facility a jail, prison, or detention center
that provides treatment exclusively for
incarcerated persons or juvenile detainees?
1
Yes
0
No
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?
SKIP TO C3 (PAGE 12)
Is this facility operated by:
For definitions of treatment approaches, go to:
https://info.nmhss.org
MARK ONE ONLY
MARK ALL THAT APPLY
1
A private for-profit organization
2
A private non-profit organization
3
A public agency or department
SKIP TO
A10 (NEXT
COLUMN)
SKIP TO
A9a (TOP
OF NEXT
COLUMN)
1
Individual psychotherapy
2
Couples/family therapy
3
Group therapy
4
Cognitive behavioral therapy
5
Dialectical behavior therapy
6
Behavior modification
7
Integrated dual disorders treatment
8
Trauma therapy
9
Activity therapy
10
Electroconvulsive therapy
11
Telemedicine therapy
12
Psychotropic medication
13
Other (Specify:
)
14
None of these mental health treatment
approaches are offered
2
*A12. Which of these services and practices are
offered at this facility, at this location?
*A13. What age groups are accepted for treatment
at this facility?
For definitions, go to: https://info.nmhss.org
MARK “YES” OR “NO” FOR EACH
YES
Children (12 or younger) .................... 1
Adolescents (13-17) ........................... 1
Young adults (18-25) .......................... 1
Adults (26-64) ..................................... 1
Seniors (65 or older) ........................... 1
MARK ALL THAT APPLY
1
Assertive community treatment (ACT)
1.
Intensive case management (ICM)
2.
2
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
3.
4.
5.
*A14. 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
Children/adolescents with serious emotional
disturbance (SED)
10
Education services
11
Housing services
12
Supported housing
13
Psychosocial rehabilitation services
14
Vocational rehabilitation services
4
15
Supported employment
5
16
Therapeutic foster care
17
Legal advocacy
18
Psychiatric emergency walk-in services
19
Suicide prevention services
20
Consumer-run (peer support) services
Screening for tobacco use
10
21
Persons with traumatic brain injury (TBI)
Smoking/tobacco cessation counseling
11
22
Veterans
23
Nicotine replacement therapy
12
Active duty military
Non-nicotine smoking/tobacco cessation
medications (by prescription)
13
Members of military families
Other (Specify:
15
1
2
3
6
7
8
24
25
9
)
26
NO
0
0
0
0
0
None of these services and practices are offered
14
Transitional age young adults
Persons 18 and older with serious mental
illness (SMI)
Seniors or older adults
Persons with Alzheimer’s or
dementia
Persons with co-occurring mental
and substance use disorders
Persons with eating disorders
Persons with a diagnosis of post-traumatic
stress disorder (PTSD)
Persons who have experienced trauma
(excluding persons with a PTSD diagnosis)
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
3
No dedicated or exclusively designed programs
or groups are offered
*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
*A17b. 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:
*A16. 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)?
Mark “yes” if either staff or an on call interpreter
provides this service.
1
Yes
0
No
4
Ojibwa
2
Lakota
5
Yupik
3
Navajo
Other American Indian or Alaska Native
Language (Specify:
____________________________________)
Other Languages:
1
Yes
0
No, only English
SKIP TO A18
(NEXT COLUMN)
A17a. At this facility, who provides mental health
treatment services in a language other than
English?
MARK ONE ONLY
7
Arabic
16
Hmong
8
Any Chinese Language
17
Italian
9
Creole
18
Japanese
10
Farsi
19
Korean
11
French
20
Polish
12
German
21
Portuguese
13
Greek
22
Russian
14
Hebrew
23
Tagalog
15
Hindi
24
Vietnamese
25
Any other language (Specify:
____________________________________)
1
Staff who speak a language other than English
2
On-call interpreter (in person or by phone)
brought in when needed
SKIP TO A18
(NEXT COLUMN)
Hopi
6
*A17. Does this facility provide mental health treatment
services in a language other than English at this
location?
3
1
A18.
Which of these quality improvement practices
are part of this facility’s standard operating
procedures?
BOTH staff and on-call interpreter
MARK “YES” OR “NO” FOR EACH
*A17a1. Do staff provide mental health treatment
services in Spanish at this facility?
YES
NO
1. Continuing education requirements for
professional staff ............................................ 1
0
0
appointed quality review committee ............... 1
0
treatment services in any other languages?
4. Client outcome follow-up after discharge ....... 1
0
1
Yes
SKIP TO A17b (TOP OF NEXT COLUMN)
5. Periodic utilization review ............................... 1
0
0
No
SKIP TO A18 (NEXT COLUMN)
6. Periodic client satisfaction surveys ................. 1
0
1
Yes
0
No
2. Regularly scheduled case review with
SKIP TO A17b (TOP OF NEXT COLUMN)
a supervisor .................................................... 1
3. Regularly scheduled case review by an
A17a2. Do staff at this facility provide mental health
4
*A19. Which of the following statements BEST
describes this facility’s smoking policy for
clients?
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.
MARK ONE ONLY
1
Not permitted to smoke anywhere outside or
within any building
Computer/
Electronic
Only
Function
2
3
N
1
2
3
N
1
2
3
N
1
2
3
N
1
2
3
N
6. Discharge
1
2
3
N
7. Referrals
1
2
3
N
1
2
3
N
1
2
3
N
medication
interactions
1
2
3
N
1
2
3
N
1
2
3
N
1
2
3
N
1
2
3
N
Permitted in designated outdoor area(s)
1. Intake
3
Permitted anywhere outside
2. Scheduling
4
Permitted in designated indoor area(s)
5
Permitted anywhere inside
6
Permitted anywhere without restriction
appointments
3. Assessment/
evaluation
4. Treatment plan
monitoring
1
Yes
0
No
8. Issue/receive lab
results
9. Prescribing/
dispensing
medication
A20a. Does this facility have any policies in place to
minimize the use of seclusion or restraint?
N/A
In the 12-month period beginning May 1, 2017,
and ending April 30, 2018, have staff at this
facility used seclusion or restraint with clients?
Both
Electronic
and Paper
1
2
5. Client progress
A20.
Paper
Only
10. Checking
1
Yes
11. Health records
0
No
12. Collaboration with a
client’s other
providers (such as
primary care
provider)
13. Billing
14. Client or family
satisfaction
surveys
*A22. Does this facility use a sliding fee scale?
Not applicable to Veterans Administration
facilities.
5
1
Yes
SKIP TO A22a (TOP OF NEXT PAGE)
0
No
SKIP TO A23 (NEXT PAGE)
A22a. Do you want the availability of a sliding fee scale
published in SAMHSA’s online Behavioral Health
Treatment Services Locator?
Not applicable to Veterans Administration
facilities.
*A24. 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
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?
Not applicable to Veterans Administration
facilities.
YES
Yes
0
No
SKIP TO A24 (TOP OF NEXT COLUMN)
DON’T
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
0
d
0
d
0
d
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
0
d
0
d
Affairs funds ..................................... 1
0
d
16. IHS/Tribal/Urban (ITU) funds ........... 1
0
d
17. Other ................................................ 1
0
d
5. State-financed health insurance
plan other than Medicaid ................. 1
6. State mental health agency
(or equivalent) funds ....................... 1
1
NO
7. State welfare or child and family
services agency funds ..................... 1
8. State corrections or juvenile
A23a. 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
13. Community Mental Health Block
Grants .............................................. 1
14. Federal military insurance (such
as TRICARE) ................................... 1
15. U.S. Department of Veterans
(Specify: ________________________________)
6
A25. From which of these agencies or organizations
does this facility have licensing, certification, or
accreditation?
SECTION B: CLIENT/PATIENT
COUNT INFORMATION
Do not include personal-level credentials or
general business licenses such as a food service
license.
Questions B3 – B8 ask about the number of
clients/patients treated at this facility on specific dates.
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
3.
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 ......................
1
0
d
10. Other national organization, or
federal, state, or local agency ....
1
0
d
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
(Specify: _______________________________ )
B1a.
*A26. What telephone number(s) should a potential
client call to schedule an intake appointment?
Only this facility
2
This facility plus others
3
Another facility in the organization will report
client/patient counts for this facility
SKIP TO B3 (PAGE 8)
SKIP TO B2 (BELOW)
Please record the name and telephone number of
the facility that will report your client/patient
counts.
Facility name:
INTAKE TELEPHONE NUMBER(S):
Telephone: (_____) - ______After recording the facility name and
telephone number in B1a
SKIP TO C1
(PAGE 12)
1. (____) ______ - ___________ ext.______
2. (____) ______ - ___________ ext.______
1
B2.
How many facilities will be included in the
reported client/patient counts?
THIS FACILITY
1
+ ADDITIONAL FACILITIES
= TOTAL FACILITIES
On page 13 of this questionnaire, list the name and location
address of each facility included in your client/patient counts.
If you prefer, we will contact you for a list of the other facilities
included in your client/patient counts.
CONTINUE WITH QUESTION B3 (TOP OF NEXT PAGE)
7
PATIENT COUNTS: 24-HOUR HOSPITAL INPATIENT
B3.
On April 30, 2018, did any patients receive
B3a.
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 9)
On April 30, 2018, how many patients received
24-hour hospital inpatient mental health treatment
at this facility?
DO NOT count family members, friends, or other
non-treatment persons.
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
PERCENT
Male ..............................................................
Female..........................................................
GENDER
CATEGORY TOTAL: (Should=B3a or 100%)
100%
0 – 17 ............................................................
18 – 64 ..........................................................
65 and older..................................................
AGE
CATEGORY TOTAL: (Should=B3a or 100%)
100%
Hispanic or Latino .........................................
Not Hispanic or Latino ..................................
Unknown or not collected .............................
ETHNICITY
CATEGORY TOTAL: (Should=B3a or 100%)
100%
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 .............................
RACE
CATEGORY TOTAL: (Should=B3a or 100%)
LEGAL STATUS
100%
Voluntary ......................................................
Involuntary, non-forensic ..............................
Involuntary, forensic .....................................
CATEGORY TOTAL: (Should=B3a or 100%)
B3c.
OR
100%
On April 30, 2018, how many hospital inpatient beds at this facility were specifically designated for
providing mental health treatment?
NUMBER OF BEDS
(If none, enter ‘0’)
8
CLIENT COUNTS: 24-HOUR RESIDENTIAL (NON-HOSPITAL)
B4.
On April 30, 2018, 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 10)
B4a.
On April 30, 2018, how many clients received
24-hour residential mental health treatment at
this facility?
DO NOT count family members, friends, or other
non-treatment persons.
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 equal 100%.
NUMBER
CATEGORY TOTAL: (Should=B4a or 100%)
100%
0 – 17 ............................................................
18 – 64 ..........................................................
65 and older..................................................
AGE
CATEGORY TOTAL: (Should=B4a or 100%)
100%
Hispanic or Latino .........................................
Not Hispanic or Latino ..................................
Unknown or not collected .............................
ETHNICITY
CATEGORY TOTAL: (Should=B4a or 100%)
100%
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 .............................
RACE
CATEGORY TOTAL: (Should=B4a or 100%)
LEGAL STATUS
100%
Voluntary ......................................................
Involuntary, non-forensic ..............................
Involuntary, forensic .....................................
CATEGORY TOTAL: (Should=B4a or 100%)
100%
On April 30, 2018, how many residential beds at this facility were specifically designated for providing
mental health treatment?
NUMBER OF BEDS
(If none, enter ‘0’)
9
PERCENT
Male ..............................................................
Female..........................................................
GENDER
B4c.
OR
CLIENT COUNTS: LESS THAN 24-HOUR CARE (INCLUDE OUTPATIENT CLIENTS
AND PARTIAL HOSPITALIZATION/DAY TREATMENT CLIENTS)
B5.
During the month of April 2018, did any clients
receive less than 24-hour mental health treatment
at this facility, at this location?
INCLUDE OUTPATIENT CLIENTS AND
PARTIAL HOSPITALIZATION/DAY
TREATMENT CLIENTS ON THIS PAGE.
1
Yes
0
No
B5a.
During the month of April 2018, how many clients
received less than 24-hour 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, 2018.
DO NOT count family members, friends, or other
non-treatment persons.
GO TO B5a (TOP OF NEXT COLUMN)
SKIP TO B6 (PAGE 11)
OUTPATIENT CLIENTS AND PARTIAL
HOSPITALIZATION/DAY TREATMENT
CLIENTS TOTAL BOX
CONTINUE WITH QUESTION B5b (BELOW)
B5b.
For each category below, please provide a breakdown of the Clients in Less Than 24-Hour Care 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
GENDER
100%
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%)
LEGAL STATUS
100%
Hispanic or Latino .........................................
Not Hispanic or Latino ..................................
Unknown or not collected .............................
CATEGORY TOTAL: (Should=B5a or 100%)
RACE
100%
0 – 17 ............................................................
18 – 64 ..........................................................
65 and older..................................................
CATEGORY TOTAL: (Should=B5a or 100%)
ETHNICITY
PERCENT
Male ..............................................................
Female..........................................................
CATEGORY TOTAL: (Should=B5a or 100%)
AGE
OR
100%
Voluntary ......................................................
Involuntary, non-forensic ..............................
Involuntary, forensic .....................................
CATEGORY TOTAL: (Should=B5a or 100%)
100%
10
ALL MENTAL HEALTH CARE SETTINGS
Including 24-Hour Hospital Inpatient, 24-Hour Residential (non-hospital),
and Less Than 24-Hour Outpatient and Partial Hospitalization/Day Treatment
B6.
On April 30, 2018, approximately what percent of the mental health treatment clients/patients 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, 2017 through April 30, 2018, 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/patients 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’)
11
SECTION C: GENERAL INFORMATION
C1.
C1a.
If eligible, does this facility want to be listed in
SAMHSA’s online Behavioral Health Treatment
Services Locator?
The Locator can be found at:
https://findtreatment.samhsa.gov
1
Yes
0
No
SKIP TO C2 (BELOW)
Information to be shared would be: facility name,
location address, telephone number, and website
address.
C2.
Yes
0
No
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
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?
1
C3.
1
Ms.
5
Other (Specify:
2
Mrs.
3
Mr.
4
Dr.
)
Name:
Title:
Phone Number: (_____) _______ - _______ Ext.
Fax Number:
(_____) _______ - _______
Email Address:
Facility Email Address:
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 (NEXT COLUMN)
*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: _________________________________
12
ADDITIONAL FACILITIES INCLUDED IN CLIENT/PATIENT COUNTS
Complete this section if you reported clients/patients for this facility plus additional facilities, as indicated in
Question B2.
For each additional facility, please mark if that facility offers hospital inpatient, residential, outpatient mental health
treatment, and/or partial hospitalization/day treatment at that location.
FACILITY NAME:
FACILITY NAME:
ADDRESS:
ADDRESS:
CITY:
CITY:
STATE:
ZIP:
STATE:
TELEPHONE:
TELEPHONE:
FACILITY EMAIL
ADDRESS:
FACILITY EMAIL
ADDRESS:
HOSPITAL INPATIENT
RESIDENTIAL
OUTPATIENT
HOSPITAL INPATIENT
ZIP:
RESIDENTIAL
OUTPATIENT
PARTIAL HOSPITALIZATION/DAY TREATMENT
PARTIAL HOSPITALIZATION/DAY TREATMENT
FACILITY NAME:
FACILITY NAME:
ADDRESS:
ADDRESS:
CITY:
CITY:
STATE:
ZIP:
STATE:
TELEPHONE:
TELEPHONE:
FACILITY EMAIL
ADDRESS:
FACILITY EMAIL
ADDRESS:
HOSPITAL INPATIENT
RESIDENTIAL
OUTPATIENT
HOSPITAL INPATIENT
ZIP:
RESIDENTIAL
OUTPATIENT
PARTIAL HOSPITALIZATION/DAY TREATMENT
PARTIAL HOSPITALIZATION/DAY TREATMENT
FACILITY NAME:
FACILITY NAME:
ADDRESS:
ADDRESS:
CITY:
CITY:
STATE:
ZIP:
STATE:
TELEPHONE:
TELEPHONE:
FACILITY EMAIL
ADDRESS:
FACILITY EMAIL
ADDRESS:
HOSPITAL INPATIENT
RESIDENTIAL
OUTPATIENT
PARTIAL HOSPITALIZATION/DAY TREATMENT
HOSPITAL INPATIENT
ZIP:
RESIDENTIAL
PARTIAL HOSPITALIZATION/DAY TREATMENT
If you require additional space, please continue on the next page.
13
OUTPATIENT
ANY ADDITIONAL COMMENTS
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 0aa(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 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, 5600 Fishers Lane, Room
15E57-B, Rockville, Maryland 20857.
14
| File Type | application/pdf |
| File Title | 2016 N-MHSS SURVEY VARIABLE |
| Subject | SAQ NON STANDARD |
| Author | MATHEMATICA STAFF |
| File Modified | 2016-12-06 |
| File Created | 2016-12-06 |