OMB No. 0930-03xx
Expiration Date: xx/xx/xx
Attachment 1
Site Survey
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 0930-0xxx. Public reporting burden for this collection of information is estimated to average 12 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.
Site Survey
Instructions: This survey focuses on how centers across the U.S. are providing services to individuals with First Episode Psychosis (FEP) in their communities.
One person from each clinical site should complete this survey. The person completing the survey should be knowledgeable about the first episode psychosis (FEP) services provided your clinical site.
The survey will take approximately 10 minutes to complete. Please do not skip questions or leave any of the questions blank, unless the option is provided.
What is your role with the First Episode Psychosis Program [text]?
In which city is your First Episode Psychosis Program located [text/option to skip]?
In which state(s) or territory is your First Episode Psychosis Program located [text/option to skip]?
When did your center start serving people with mental illnesses? [drop down menu for month; year]
When did your center start focusing on people with first episode psychosis? [drop down menu for month; year]
What is the age range of FEP participants that are eligible to enroll in your program? [drop down menu for minimum age; maximum age]
Currently, how many people are served in your FEP program? [number]
On average, how many people do you serve in your FEP program each month? [number]
What is the maximum capacity for people you can serve in your FEP program each month? [number]
If your program has an inclusion/enrollment criteria about the amount of time since the person first experienced their onset of psychosis, what is that amount of time? [number of months/ program does not have this criteria]
Does your program have an inclusion/enrollment criteria about whether the person has been previous prescribed with an antipsychotic medication? [yes/no]
Which of the following models did your FEP program receive technical assistance or training from (select all that apply)?
☐ NAVIGATE
☐ OnTrack
☐ EASA
☐ PIER
☐ FIRST
☐ Other model not listed
☐ Don’t know
Do you assess fidelity to your FEP model?
☐ Yes (if yes: How often do you assess the fidelity?__________________)
(if yes: What fidelity instrument do you use? __________________)
☐ No
☐ Don’t know
What is the average length of time that clients are enrolled in your FEP program before they graduate?
☐ Less than 12 months
☐ 1-2 Years
☐ More than 2 years
☐ Don’t know
Which of the following diagnoses do the individuals who enroll in your FEP program have? (select all that apply)
☐ Schizophrenia
☐ Schizoaffective disorder
☐ Schizophreniform disorder
☐ Delusional disorder
☐ Psychotic disorder not otherwise specified
☐ Affective disorders (depressive disorders, bipolar disorder) with psychotic features
☐ Affective disorders (depression, bipolar disorder, anxiety) without psychotic features
☐ Post-Traumatic Stress Disorder (PTSD)
☐ Other (specify): ____________________________________________
☐ Don’t know
☐ Not applicable
Which of the following resources or strategies does your FEP program use to identify potential clients and obtain referrals? (select all that apply)
☐ Program website
☐ Brochures or flyers
☐ Centralized phone lines for referrals
☐ Presentations about the program
☐ Newsletters
☐ Social media
☐ Linkage/communication with psychiatric inpatient facilities
☐ Linkage/communication with outpatient mental health clinics
☐ Linkage/communication with emergency departments
☐ Linkage/communication with primary care
☐ Linkage/communication with courts/correctional facilities
☐ Partnerships with colleges, schools, or other educational institutions
☐ Partnerships with consumer, professional, or family organizations
☐ Other (specify): ____________________________________
☐ Don’t know
What types of insurance are accepted by your program for payment for services? (select all that apply)
☐ Medicaid
☐ Medicare
☐ Private insurance
☐ Uninsured
☐ Don’t know
☐ Not applicable
Does your FEP Program have a designated Team Lead?
☐ Yes
☐ No
Approximately how many full-time equivalent (FTE) staff positions are part of your FEP Service Team? [number]
What treatment services and supports are involved in your FEP program model? (select all that apply)
☐ Case Management
☐ Supported Employment
☐ Supported Education
☐ Occupational Therapy
☐ Cognitive-Behavioral Psychotherapy (individual or group therapy)
☐ Family Education or Family Support
☐ Evidence-based pharmacotherapy
☐ Primary Care Coordination
☐ Cognitive Remediation
☐ Peer Support Services
☐ Neuropsychological Assessment
☐ Mobile Outreach
☐ Crisis Intervention Services
☐ Co-occurring Substance Use Services
☐ Smoking Cessation Services
☐ Weight Loss Support and Services
☐ Housing Support and Services
☐ Other services and supports (specify): ____________________________________
☐ Don’t know
☐ Not currently providing services
What types of strategies are used to engage families of FEP clients (select all that apply)?
☐ Family members are invited to participate during the intake process
☐ Family members are invited to participate during treatment sessions with FEP clients
☐ Family members are offered educational materials
☐ Family members are offered structured psychoeducational services
☐ Family members are offered hopeful messages and communications
☐ Family members are offered flexibility and extended hours for appointments
☐ Other strategies (specify): ____________________________________
☐ Don’t know
☐ Not applicable
Does your program offer community visits to see clients outside the office/clinic setting?
☐ Yes
☐ No
☐ Don’t know
Has your program provided FEP training to staff in any of the following areas (select all that apply):
☐ Rationale for early intervention with FEP
☐ Components and fundamentals of Coordinated Specialty Care
☐ Recovery for FEP clients
☐ Developmental issues specific to adolescents or young adults
☐ Shared decision making and person-centered care
☐ Client/family engagement
☐ Client risk for substance use problems
☐ Client risk for suicide
☐ This program does not provide FEP training for staff
☐ Don’t know
Which of the following outcome measures does your FEP Program collect about clients? (select all that apply)
☐ Symptom Severity
☐ Employment
☐ School participation
☐ Homelessness
☐ Criminal justice involvement
☐ Independent living
☐ Social connectedness
☐ Program Engagement
☐ Substance Use
☐ Suicidality
☐ Psychiatric Hospitalization
☐ Use of Emergency Rooms
☐ Prescription Medication Adherence and Side Effects
☐Other (specify):_______________________________
☐Don’t know
☐Not currently providing services to clients
☐Not collecting outcome measures
Is there a designated person at your site who looks at client outcome data regularly?
☐ Yes
☐ No
How does your FEP program model measure duration of untreated psychosis? [open text field]
Was your FEP program started using State Mental Health Block Grant set aside funds for early interventions?
☐ Yes
☐ No
☐ Don’t know
Does your FEP program receive financial support from sources other than the state mental health block grant funds?
☐ Yes (if yes: Which sources?__________________)
☐ No
☐ Don’t know
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Preethy George |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |