Form Locator Survey Locator Survey Locator Survey

Attachment A.2_2021 N-MHSS-Locator Survey Paper Questionnaire (also for Between-Survey Update)

OMB No. xxxx-xxxx

APPROVAL EXPIRES: xx/xx/xxxx

See OMB burden statement on last page

2021 National Mental Health Services Survey

(N-MHSS)

April 30, 2021

Substance Abuse and Mental Health Services Administration (SAMHSA)

U.S. Department of Health and Human Services (HHS)

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

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, 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 any questions or need additional blank surveys, contact:

mathematica

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, in SAMHSA’s National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C1, page 9, 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 as mental health facilities 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.

• prepared by mathematica

• prepared by mathematica

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 treatment 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/or 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. Treatment for co-occurring 1  0 

mental illness/serious emotional disturbance (SED) in children and substance use disorders

6. Substance use disorder treatment 1  0 

7. Administrative or operational services 1  0 

for mental health treatment facilities

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

1  Yes SKIP TO A3 (TOP OF NEXT COLUMN)

0  No SKIP TO C2 (PAGE 9)

*A3. Mental health treatment is provided in which of the following service settings at this facility, at this location?

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 

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

• For definitions of facility types, go to: https://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

4  Residential treatment center for adults

5  Other type of residential treatment facility

6  Veterans Administration Medical Center (VAMC) or other VA health care facility

7  Community Mental Health Center (CMHC)

8  Certified Community Behavioral Health Clinic (CCBHC)

9  Partial hospitalization/day treatment facility

10  Outpatient mental health facility

11  Multi-setting mental health facility (non-hospital residential plus either outpatient and/or partial hospitalization/day treatment)

12  Other (Specify:

)

A5. Is this facility either a solo or a 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 C2 (PAGE 9)

*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 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  Yes

0  No

d  Don’t know

A7. Does this facility, at this location, provide any of the following services?

MARK ALL THAT APPLY

1 □ Assisted living or nursing home care

2 □ Supported housing

3 □ Group homes

4 □ Clubhouse services

5 □ Emergency shelter (such as homeless, domestic violence, etc.)

6 □ Care for only individuals with a developmental disability (that is, significant limitations in intellectual functioning)

7 □ None of these services

A8. 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  Mental health treatment

2  Substance use
treatment SKIP TO C2 (PAGE 9)

3  Mix of mental health and substance use treatment (neither is primary)

4  General health care

5  Other service focus (Specify:

)

A9. Is this facility a jail, prison, or detention center that provides treatment exclusively for incarcerated persons or juvenile detainees?

1  Yes SKIP TO C2 (PAGE 9)

0  No SKIP TO A10 (TOP OF NEXT PAGE)

*A10. 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

*A10a. 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 county, local, or municipal government

4  Tribal government

5  Indian Health Service

6  Department of Veterans Affairs

7  Other (Specify:

)

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

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

MARK ALL THAT APPLY

1  Individual psychotherapy

2  Couples/family therapy

3  Group therapy

4  Cognitive behavioral therapy

5  Dialectical behavior therapy

6  Cognitive remediation

7  Integrated mental health and substance use treatment

8  Trauma therapy

9  Activity therapy

10  Electroconvulsive therapy

11  Transcranial Magnetic Stimulation (TMS)

12  Ketamine Infusion Therapy (KIT)

13  Eye Movement Desensitization and Reprocessing (EMDR) therapy

14  Telemedicine/telehealth therapy

15  Other (Specify:

)

16  None of these mental health treatment modalities are offered

*A12. Does this facility offer pharmacotherapy, that is, the use of antipsychotics for the treatment of serious mental illness (SMI)?

1  Yes

0  No SKIP TO A13 (TOP OF NEXT PAGE)

*A12a. Which of the following antipsychotics are used for the treatment of SMI at this facility, at this location?

	Mark ALL THAT APPLY for Each MEDICATION
FIRST-GENERATION ANTIPSYCHOTIC	Oral	Injectable	Long-acting Injectable	Not used at this facility
1. Chlorpromazine (Thorazine®)	1 	2 	3 	4 
2. Droperidol (Inapsine®)	1 	2 	3 	4 
3. Fluphenazine (Prolixin®)	1 	2 	3 	4 
4. Haloperidol (Haldol®)	1 	2 	3 	4 
5. Loxapine (Loxitane®)	1 	2 	3 	4 
6. Perphenazine (Trilafon/Etrafon/Triavil/Triptafen®)	1 	2 	3 	4 
7. Pimozide (Orap®)	1 	2 	3 	4 
8. Prochlorperazine (Compazine/Compro®)	1 	2 	3 	4 
9. Thiothixene (Navane®)	1 	2 	3 	4 
10. Thioridazine (Mellaril/Melleril®)	1 	2 	3 	4 
11. Trifluoperazine (Stelazine®)	1 	2 	3 	4 
12. Other first-generation antipsychotics (Specify: )	1 	2 	3 	4 

	Mark ALL THAT APPLY for Each MEDICATION
SECOND-GENERATION ANTIPSYCHOTIC	Oral	Injectable	Long-acting Injectable	Not used at this facility
13. Aripiprazole (Abilify®)	1 	2 	3 	4 
14. Asenapine (Saphris/Sycrest®)	1 	2 	3 	4 
15. Clozapine (Clozaril®)	1 	2 	3 	4 
16. IIoperidone (Fanapt®)	1 	2 	3 	4 
17. Olanzapine (Zyprexa®)	1 	2 	3 	4 
18. Paliperidone (Invega Trinza®)	1 	2 	3 	4 
19. Quetiapine (Seroquel®)	1 	2 	3 	4 
20. Risperidone (Risperdal®)	1 	2 	3 	4 
21. Ziprasidone (Geodon®)	1 	2 	3 	4 
22. Other second- antipsychotics (Specify: )	1 	2 	3 	4 

*A13. Which of these services and practices are offered at this facility, at this location?

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

MARK ALL THAT APPLY

1  Assertive community treatment (ACT)

2  Intensive case management (ICM)

3  Case management (CM)

4  Court-ordered treatment

5  Assisted Outpatient Treatment (AOT)

6  Chronic disease/illness management (CDM)

7  Illness management and recovery (IMR)

8  Integrated primary care services

9  Diet and exercise counseling

10  Family psychoeducation

11  Education services

12  Housing services

13  Supported housing

14  Psychosocial rehabilitation services

15  Vocational rehabilitation services

16  Supported employment

17  Therapeutic foster care

18  Legal advocacy

19  Psychiatric emergency walk-in services

20  Suicide prevention services

21  Peer support services

22  Testing for Hepatitis B (HBV)

23  Testing for Hepatitis C (HCV)

24  HIV testing

25  STD testing

26  TB screening

27  Screening for tobacco use

28  Smoking/vaping/tobacco cessation counseling

29  Nicotine replacement therapy

30  Non-nicotine smoking/tobacco cessation medications (by prescription)

31  Other (Specify:

)

32  None of these services and practices are offered

A14. Did you answer “yes” to treatment for co-occurring mental illness/serious emotional disturbance (SED) in children and substance use disorders in question A1 above (option 5)?

1  Yes

0  No SKIP TO A16 (TOP OF NEXT PAGE)

A15. Which of the following services are provided to clients with co-occurring mental health and substance use disorders at this facility?

MARK ALL THAT APPLY

1  Detoxification (medical withdrawal)

2  Medication assisted treatment for alcohol use disorder (for example, disulfiram, acamprosate)

3  Medication assisted treatment for opioid use disorder (for example, buprenorphine, methadone, naltrexone)

4  Individual counseling

5  Group counseling

6  12-Step groups

7  Case management

8  None of these services are offered

*A16. What age groups are accepted for treatment at this facility?

MARK ALL THAT APPLY

YES NO

1. Young children (0-5) 1  0 

2. Children (6-12) 1  0 

3. Adolescents (13-17) 1  0 

4. Young adults (18-25) 1  0 

5. Adults (26-64) 1  0 

6. Older adults (65 or older) 1  0 

*A17. 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  Children/adolescents with serious emotional disturbance (SED)

2  Young adults

3  Persons 18 and older with serious mental illness (SMI)

4  Older adults

5  Persons with Alzheimer’s or dementia

6  Persons with co-occurring mental and substance use disorders

7  Persons with eating disorders

8  Persons experiencing first-episode psychosis

9  Persons who have experienced intimate partner violence, domestic violence

10  Persons with a diagnosis of post-traumatic stress disorder (PTSD)

11  Persons who have experienced trauma (excluding persons with a PTSD diagnosis)

12  Persons with traumatic brain injury (TBI)

13  Veterans

14  Active duty military

15  Members of military families

16  Lesbian, gay, bisexual, transgender, or queer/questioning clients (LGBTQ)

17  Forensic clients (referred from the court/ judicial system)

18  Persons with HIV or AIDS

19  Other special program or group (Specify: _____________________________________________)

20  No dedicated or exclusively designed programs or groups are offered

*A18. 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

*A19. Does this facility offer services for psychiatric emergencies onsite?

1  Yes

0  No

*A20. Does this facility offer mobile/off-site psychiatric crisis services?

1  Yes

0  No

*A21. 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

*A22. 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 A23

(NEXT COLUMN)

A22a. At this facility, who provides mental health treatment services in a language other than English?

MARK ONE ONLY

1  Staff who speak a language other than English

2  On-call interpreter (in person or by phone) brought in when needed SKIP TO A23

(NEXT COLUMN)

3  BOTH staff and on-call interpreter

*A22a1. Do staff provide mental health treatment services in Spanish at this facility?

1  Yes SKIP TO A22a2 (TOP OF NEXT COLUMN)

0  No SKIP TO A22b (NEXT COLUMN)

A22a2. Do staff at this facility provide mental health treatment services in any other languages?

1  Yes

0  No SKIP TO A23 (BELOW)

*A22b. 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 American Indian or Alaska Native

language (Specify:

____________________________________)

Other Languages:

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:

____________________________________)

*A23. Which of the following statements BEST describes 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

*A24. Does this facility use a sliding fee scale?

• Sliding fee scales are based on income and other factors.

• Not applicable to Veterans Administration facilities.

1  Yes

0  No SKIP TO A25 (BELOW)

A24a. Do you want the availability of a sliding fee scale published in SAMHSA’s online Behavioral Health Treatment Services Locator?

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

• Not applicable to Veterans Administration facilities.

1  Yes

0  No

*A25. Does this facility offer treatment at no charge or minimal payment (for example, $1) to clients who cannot afford to pay?

• Not applicable to Veterans Administration facilities.

1  Yes

0  No SKIP TO A26 (TOP OF NEXT PAGE)

A25a. Do you want the availability of treatment at no charge or minimal payment (for example, $1) 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.

• Not applicable to Veterans Administration facilities.

1  Yes

0  No

*A26. Which of the following types of client payments, insurance, or funding are accepted by this facility for mental health treatment services?

MARK ALL THAT APPLY

1  Cash or self-payment

2  Private health insurance

3  Medicare

4  Medicaid

5  State-financed health insurance plan other than Medicaid

6  State mental health agency (or equivalent) funds

7  State welfare or child and family services agency funds

8  State corrections or juvenile justice agency funds

9  State education agency funds

10  Other state government funds

11  County or local government funds

12  Community Service Block Grants

13  Community Mental Health Block Grants

14  Federal grants

15  Federal military insurance (such as TRICARE)

16  U.S. Department of Veterans Affairs funds

17  IHS/Tribal/Urban (ITU) funds

18  Private or Community foundation

19  Other (Specify: ______________________)

A27. From which of these agencies or 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 ALL THAT APPLY

1  State mental health authority

2  State substance abuse agency

3  State department of health

4  State or local Department of Family and Children’s Services

5  Hospital licensing authority

6  The Joint Commission

7  Commission on Accreditation of Rehabilitation Facilities (CARF)

8  Council on Accreditation (COA)

9  Centers for Medicare and Medicaid Services (CMS)

10  Other national organization, or federal, state, or local agency
(Specify: ___________________________)

SECTION C: GENERAL INFORMATION

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

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

1  Yes

0  No SKIP TO C2 (NEXT COLUMN)

C1a. Does this facility want the street address and/or mailing address to be listed in SAMHSA’s online Behavioral Health Treatment Services Locator and Mental Health Directory?

MARK ALL THAT APPLY

1 ¨ Publish the street address

2 ¨ Publish the mailing address

3 ¨ Do not publish either address

C1b. To increase public awareness of behavioral health services, SAMHSA may be sharing facility information with large commercially available Internet search engines (such as Google, Bing, Yahoo!, etc.), businesses (such as any .com, .org, .edu, etc.) or individuals asking for this information for any purpose. Do you want your facility information shared?

• Information to be shared would be: facility name, location address, telephone number, website address, and all asterisked items in the questionnaire.

1  Yes

0  No

C2. 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  Mr.

3  Mrs.

4  Dr.

5  Other (Specify: )

Name:

Title:

Phone Number: (_____) _______ - _______ Ext.

Fax Number: (_____) _______ - _______

Email Address:

Facility Email Address:

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

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 the Public Health Service Act (42 USC 290aa(p)). 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 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 publicly-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 xxxx-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.

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