Form N-SSATS 2021 Quest N-SSATS 2021 Quest N-SSATS 2021 Questionnaire (Version A)

Attachment B1 N-SSATS 2021 Questionnaire (Version A) (as of 2/26/2020)

OMB No. 0930-XXXX

APPROVAL EXPIRES: XX/XX/XXXX

See OMB burden statement on last page

National Survey of

Substance Abuse Treatment Services

(N-SSATS)

March 31, 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 pink flyer enclosed in your survey 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 more information, call the N‑SSATS helpline at 1-888-324-8337.

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 1-888-324-8337.

• 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 the questionnaire has not been completed online, return the completed questionnaire in the envelope provided. Please keep a copy for your records.

• For additional information about this survey and definitions of some of the terms used, please visit our website at https://info.nssats.com.

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

MATHEMATICA POLICY RESEARCH

1-888-324-8337

NSSATSWeb@mathematica-mpr. com

IMPORTANT INFORMATION

_* Asterisked questions. Information from asterisked (*) questions may be published in SAMHSA’s online Behavioral Health Treatment Services Locator (found at https://findtreatment.samhsa.gov), in SAMHSA’s National Directory of Drug and Alcohol Abuse Treatment Programs, and other publicly-available listings, unless you designate otherwise in question 28, page 10 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 location.

Eligibility for online Locator and Directory. Only facilities designated as eligible by their state substance abuse office and that complete this questionnaire will be listed as substance abuse facilities in the online Locator and Directory. Your state N‑SSATS representative can tell you if your facility is eligible to be listed in the online Locator and Directory. For the name and telephone number of your state representative, call the N‑SSATS helpline at 1-888-324-8337.

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.

*1. Which of the following substance abuse services are offered by this facility at this location, that is, the location listed on the front cover?

MARK “YES” OR “NO” FOR EACH

YES NO

1. Intake, assessment, or referral 1  0 

2. Detoxification 1  0 

3. Substance use treatment 1  0 

(services that focus on initiating and maintaining an individual’s recovery from substance abuse and on averting relapse)

4. Treatment for co-occurring serious

mental illness (SMI)/serious emotional

disturbance (SED) and substance use

disorders 1  0 

5. Any other substance abuse

services 1  0 

1a. To which of the following clients does this facility, at this location, offer mental health treatment services (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)?

MARK ALL THAT APPLY

1  Substance abuse clients

2  Clients other than substance abuse clients

3  No clients are offered mental health treatment services

2. Is this facility a jail, prison, or other organization that provides treatment exclusively for incarcerated persons or juvenile detainees?

1  Yes SKIP TO Q.37 (PAGE 14)

0  No

3. Did you answer “yes” to detoxification in option 2 of question 1 above?

1  Yes SKIP TO Q.3a (TOP OF NEXT COLUMN)

0  No SKIP TO Q.4 (NEXT COLUMN)

*3a. Does this facility detoxify clients from . . .

MARK ALL THAT APPLY

1  Alcohol

2  Benzodiazepines

3  Cocaine

4  Methamphetamines

5  Opioids

6  Other (Specify: )

*3b. Does this facility routinely use medications during detoxification?

1  Yes

0  No

4. Did you answer “yes” to substance use treatment in option 3 of question 1?

1  Yes

0  No SKIP TO Q.25 (PAGE 10)

5. Is this facility a solo practice, meaning, an office with only one independent practitioner or counselor?

1  Yes

0  No

*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.nssats.com

1  Yes

0  No

d  Don’t know

7. What is the primary focus of this facility at this location, that is, the location listed on the front cover?

MARK ONE ONLY

1  Substance use treatment services

2  Mental health services

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

4  General health care

5  Other (Specify: )

*8. Is this facility operated by . . .

MARK ONE ONLY

1  A private for-profit organization

2  A private non-profit organization

3  State government

4  Local, county, or community government

5  Tribal government

6  Federal Government

*8a. Which Federal Government agency?

MARK ONE ONLY

1  Department of Veterans Affairs

2  Department of Defense

3  Indian Health Service

4  Other (Specify: )

*9. Does this facility offer HOSPITAL INPATIENT substance abuse services at this location, that is, the location listed on the front cover?

1  Yes

0  No SKIP TO Q.10 (BELOW)

*9a. Which of the following HOSPITAL INPATIENT services are offered at this facility?

MARK “YES” OR “NO” FOR EACH

YES NO

1. Hospital inpatient detoxification 1 ¨ 0 ¨

(similar to ASAM Levels IV-D and III.7-D, medically managed or monitored inpatient detoxification)

2. Hospital inpatient treatment 1 ¨ 0 ¨

(similar to ASAM Levels IV and III.7, medically managed or monitored intensive inpatient treatment)

NOTE: ASAM is the American Society of Addiction Medicine.

For more information on ASAM please go to https://info.nssats.com.

*10. Does this facility offer RESIDENTIAL (non‑hospital) substance abuse services at this location, that is, the location listed on the front cover?

1  Yes SKIP TO Q.10a (TOP OF NEXT COLUMN)

0  No SKIP TO Q.11 (NEXT COLUMN)

*10a. Which of the following RESIDENTIAL services are offered at this facility?

MARK “YES” OR “NO” FOR EACH

YES NO

1. Residential detoxification 1 ¨ 0 ¨

(similar to ASAM Level III.2-D, clinically managed residential detoxification or social detoxification)

2. Residential short-term treatment 1 ¨ 0 ¨

(similar to ASAM Level III.5, clinically managed high-intensity residential treatment, typically 30 days or less)

3. Residential long-term treatment 1 ¨ 0 ¨

(similar to ASAM Levels III.3 and III.1, clinically managed medium- or low-intensity residential treatment, typically more than 30 days)

*11. Does this facility offer OUTPATIENT substance abuse services at this location, that is, the location listed on the front cover?

1  Yes

0  No SKIP TO Q.12 (TOP OF NEXT PAGE)

*11a. Which of the following OUTPATIENT services are offered at this facility?

MARK “YES” OR “NO” FOR EACH

YES NO

1. Outpatient detoxification 1 ¨ 0 ¨

(similar to ASAM Levels I-D and II-D, ambulatory detoxification)

2. Outpatient methadone/
buprenorphine maintenance or
naltrexone treatment 1 ¨ 0 ¨

3. Outpatient day treatment

or partial hospitalization 1 ¨ 0 ¨

(similar to ASAM Level II.5, 20 or more hours per week)

4. Intensive outpatient treatment 1 ¨ 0 ¨

(similar to ASAM Level II.1, 9 or more hours per week)

5. Regular outpatient treatment 1 ¨ 0 ¨

(similar to ASAM Level I, outpatient treatment, non-intensive)

*12. Which of the following services are offered by this facility at this location, that is, the location listed on the front cover?

MARK ALL THAT APPLY

Assessment and Pre-Treatment Services

1  Screening for substance abuse

2  Screening for mental disorders

3  Comprehensive substance abuse assessment or diagnosis

4  Comprehensive mental health assessment or diagnosis (for example, psychological or psychiatric evaluation and testing)

5  Screening for tobacco use

6  Outreach to persons in the community who may need treatment

7  Interim services for clients when immediate admission is not possible

8  Professional interventionist/educational consultant

9  We do not offer any of these assessment and pre‑treatment services

Testing (include tests performed at this location, even if specimen is sent to an outside source for chemical analysis.)

10  Drug and alcohol oral fluid testing

11  Breathalyzer or other blood alcohol testing

12  Drug or alcohol urine screening

13  Testing for Hepatitis B (HBV)

14  Testing for Hepatitis C (HCV)

15  HIV testing

16  STD testing

17  TB screening

18  Testing for metabolic syndrome

19  We do not offer any of these testing services

Medical Services

20  Hepatitis A (HAV) vaccination

21  Hepatitis B (HBV) vaccination

22  We do not offer any of these medical services

Transitional Services

23  Discharge planning

24  Aftercare/continuing care

25  Naloxone and overdose education

26  Outcome follow-up after discharge

27  We do not offer any of these transitional services

Recovery Support Services

28  Mentoring/peer support

29  Self-help groups (for example, AA, NA, SMART Recovery)

30  Assistance in locating housing for clients

31  Employment counseling or training for clients

32  Assistance with obtaining social services (for example, Medicaid, WIC, SSI, SSDI)

33  Recovery coach

34  We do not offer any of these recovery support services

Education and Counseling Services

35  HIV or AIDS education, counseling, or support

36  Hepatitis education, counseling, or support

37  Health education other than HIV/AIDS or Hepatitis

38  Substance abuse education

39  Smoking/tobacco cessation counseling

40  Individual counseling

41  Group counseling

42  Family counseling

43  Marital/couples counseling

44  Vocational training or educational support (for example, high school coursework, GED preparation, etc.)

45  We do not offer any of these education and counseling services

Ancillary Services

46  Case management services

47  Social skills development

48  Child care for clients’ children

49  Domestic violence—family or partner violence services (physical, sexual, and emotional abuse)

50  Early intervention for HIV

51  Transportation assistance to treatment

52  Mental health services

53  Acupuncture

54  Residential beds for clients’ children

55  We do not offer any of these ancillary services

Other Services

56  Treatment for gambling disorder

57  Treatment for Internet use disorder

58  Treatment for other addiction disorder (non‑substance abuse)

59  We do not offer any of these other services

*12. (continued)

Pharmacotherapies

60  Disulfiram (Antabuse^®)

61  Naltrexone (oral)

62  Naltrexone (extended-release, injectable, for example, Vivitrol^®)

63  Acamprosate (Campral^®)

64  Nicotine replacement

65  Non-nicotine smoking/tobacco cessation medications (for example, bupropion, varenicline)

66  Medications for psychiatric disorders

67  Methadone

68  Buprenorphine with naloxone (for example, Suboxone^®, Bunavail^®, Zubsolv^®, Cassipa^®)

69  Buprenorphine without naloxone

70  Buprenorphine sub-dermal implant (Probuphine^®)

71  Buprenorphine (extended-release, injectable, for example, Sublocade^®)

72  Medications for HIV treatment (for example, antiretroviral medications such as tenofovir, efavirenz, emtricitabine, atazanavir, and lamivudine)

73  Medications for Hepatitis C (HCV) treatment (for example, sofosbuvir, ledipasvir, interferon, peginterferon, ribavirin)

74  Lofexidine

75  Clonidine

76  We do not offer any of these pharmacotherapy services

*13. Facilities may treat a range of substance use disorders. The next series of questions focuses only on how this facility treats opioid use disorder.

How does this facility treat opioid use disorder?

• Medication assisted treatment (MAT) includes the use of methadone, buprenorphine and/or naltrexone for the treatment of opioid use disorder. For this question, MAT refers to any or all of these medications unless specified.

MARK ALL THAT APPLY

1  This facility does not treat opioid use disorder.

SKIP TO Q.14

(TOP OF PAGE 6)

2  This facility uses methadone or buprenorphine for pain management, emergency cases, or research purposes. It is NOT a federally-certified Opioid Treatment Program (OTP).

3  This facility treats opioid use disorder, but it does not use medication assisted treatment (MAT), nor does it accept clients using MAT to treat opioid use disorder.

4  This facility accepts clients using MAT, but the medications originate from or are prescribed by another entity. (The medications may or may not be stored/delivered/monitored onsite.) SKIP TO Q.13a (TOP OF NEXT PAGE)

5  This facility administers naltrexone to treat opioid use disorder. Naltrexone use is authorized through any medical staff who have prescribing privileges.

SKIP TO
Q.13b

(NEXT PAGE)

6  This facility prescribes buprenorphine to treat opioid use disorder. Buprenorphine use is authorized through a DATA 2000 waivered physician, physician assistant, or nurse practitioner.

7  This facility is a federally-certified Opioid Treatment Program (OTP). (Most OTPs administer/dispense methadone; some only use buprenorphine.)

*13a. For those clients using MAT, but whose medications originate from or are prescribed by another entity, from where do these clients obtain their medications?

MARK ALL THAT APPLY

1  The prescribing entity is in our network.

2  There is a business, contractual, or formal referral relationship with the prescribing entity.

3  The client obtains their prescription/medication from their personal physician/health care provider.

4  Other (Specify: ______________________________________________________ )

*13b. Does this facility serve only opioid use disorder clients?

1  Yes

0  No

*13c. Which of the following medication services does this program provide?

MARK ALL THAT APPLY

1  Maintenance services with methadone or buprenorphine

2  Maintenance services with medically-supervised withdrawal (or taper) after a period of stabilization

3  Detoxification from opioids of abuse with methadone or buprenorphine

4  Detoxification from opioids of abuse with lofexidine or clonidine

5  Relapse prevention with naltrexone

6  Other (Specify: ______________________________________________________ )

7  We do not offer any of these medication services

13d. Approximately what percent of clients on MAT receive the following medication services for opioid use disorder?

Service	MARK ONE BOX FOR EACH SERVICE
	Not Offered	33% or less	34% to 67%	more than 67%
1. Maintenance services with methadone or buprenorphine	0 	1 	2 	3 
2. Maintenance services with medically-supervised withdrawal (or taper) after a period of stabilization	0 	1 	2 	3 
3. Detoxification from opioids of abuse with methadone or buprenorphine	0 	1 	2 	3 
4. Detoxification from opioids of abuse with lofexidine or clonidine	0 	1 	2 	3 
5. Relapse prevention with naltrexone	0 	1 	2 	3 
6. Enter the Other Specify value(s) from 13c here:	0 	1 	2 	3 

*14. Facilities may treat a range of substance use disorders. The next series of questions focuses only on how this facility treats alcohol use disorder.

How does this facility treat alcohol use disorder?

• These medications have been approved by the FDA to treat alcohol use disorder: naltrexone, acamprosate, and disulfiram. For this question, MAT refers to any or all of these three medications.

MARK ALL THAT APPLY

1  This facility does not treat alcohol use disorder. SKIP TO Q.15 (BELOW)

2  This facility treats alcohol use disorder, but it does not use medication assisted treatment (MAT) for alcohol use disorder, nor does it accept clients using MAT to treat alcohol use disorder. SKIP TO Q.14b (BELOW)

3  This facility accepts clients using MAT for alcohol use disorder, but the medications originate from or are prescribed by another entity.

4  This facility administers/prescribes at least one of disulfiram (Antabuse^®), naltrexone, and/or acamprosate (Campral^®) for alcohol use disorder. SKIP TO Q.14b (BELOW)

*14a. For those clients using MAT for alcohol use disorder, but whose medications originate from or are prescribed by another entity, from where do these clients obtain their medications?

MARK ALL THAT APPLY

1  The prescribing entity is in our network.

2  There is a business, contractual, or formal referral relationship with the prescribing entity.

3  The client obtains their prescription/medication from their personal physician/health care provider.

4  Other (Specify: ______________________________________________________ )

*14b. Does this facility serve only alcohol use disorder clients?

1  Yes

0  No

*15. Which of the following clinical/therapeutic approaches listed below are used frequently at this facility?

MARK ALL THAT APPLY

1  Substance abuse counseling

2  12-step facilitation

3  Brief intervention

4  Cognitive behavioral therapy

5  Dialectical behavior therapy

6  Contingency management/motivational incentives

7  Motivational interviewing

8  Trauma-related counseling

APPROTH

APPROTH_SPEC

9  Anger management

10  Matrix Model

11  Community reinforcement plus vouchers

12  Rational emotive behavioral therapy (REBT)

13  Relapse prevention

14  Telemedicine/telehealth (including Internet, Web, mobile, and desktop programs)

15  Other treatment approach (Specify: _________________________________________________ )

16  We do not use any of these clinical/therapeutic approaches

*16. Does this facility, at this location, offer a specially designed program or group intended exclusively for DUI/DWI or other drunk driver offenders?

1  Yes

0  No SKIP TO Q.17 (BELOW)

*16a. Does this facility serve only DUI/DWI clients?

1  Yes

0  No

*17. Does this facility provide substance use 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 a staff counselor or an on‑call interpreter provides this service.

1  Yes

0  No

*18. Does this facility provide substance use treatment services in a language other than English at this location?

1  Yes

0  No SKIP TO Q.19 (TOP OF NEXT PAGE)

18a. At this facility, who provides substance use treatment services in a language other than English?

MARK ONE ONLY

1  Staff counselor who speaks a language other than English

2  On-call interpreter (in person or by phone) brought in when needed SKIP TO Q.19

(TOP OF NEXT PAGE)

3  BOTH staff counselor and on-call interpreter

*18a1. Do staff counselors provide substance use treatment in Spanish at this facility?

1  Yes

0  No SKIP TO Q.18b (TOP OF NEXT COLUMN)

18a2. Do staff counselors at this facility provide substance use treatment in any other languages?

1  Yes SKIP TO Q.18b (TOP OF NEXT COLUMN)

0  No SKIP TO Q.19 (TOP OF NEXT PAGE)

*18b. In what other languages do staff counselors provide substance use treatment at this facility?

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

MARK ALL THAT APPLY

American Indian or Alaska Native:

1  Hopi

2  Lakota

3  Navajo

4  Ojibwa

5  Yupik

6  Other American Indian or Alaska Native language

(Specify: )

Other Languages:

7  Arabic

8  Any Chinese language

9  Creole

10  Farsi

11  French

12  German

13  Greek

14  Hebrew

15  Hindi

16  Hmong

17  Italian

18  Japanese

19  Korean

20  Polish

21  Portuguese

22  Russian

23  Tagalog

24  Vietnamese

25  Any other language

(Specify: )

*19. Individuals seeking substance use treatment can vary by age, gender or other characteristics. Which categories of individuals listed below are served by this facility, at this location?

• Indicate only the highest or lowest age the facility would accept. Do not indicate the highest or lowest age currently receiving services in the facility.

Type of Client	MARK “YES” OR “NO” FOR EACH CATEGORY		If Served, What is the Lowest Age Served		If Served, What is the Highest Age Served
	Served by this Facility
1. Female	1  Yes	0  No	| | | YEARS	0  No minimum age	| | | YEARS	0  No maximum age
2. Male	1  Yes	0  No	| | | YEARS	0  No minimum age	| | | YEARS	0  No maximum age

*19a. Many facilities have clients in one or more of the following categories. For which client categories does this facility at this location offer a substance use treatment program or group specifically tailored for clients in that category? 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  Adolescents

2  Young adults

3  Adult women

4  Pregnant/postpartum women

5  Adult men

6  Seniors or older adults

7  Lesbian, gay, bisexual, transgender (LGBT) clients

8  Veterans

9  Active duty military

10  Members of military families

11  Criminal justice clients (other than DUI/DWI)

12  Clients with co-occurring mental and substance use disorders

13  Clients with co-occurring pain and substance use

14  Clients with HIV or AIDS

15  Clients who have experienced sexual abuse

16  Clients who have experienced intimate partner violence, domestic violence

17  Clients who have experienced trauma

18  Specifically tailored programs or groups for any other types of clients

(Specify: )

19  No specifically tailored programs or groups are offered

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

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

1  Yes

0  No SKIP TO Q.21 (BELOW)

20a. Do you want the availability of a sliding fee scale published in SAMHSA’s online Locator and Directory?

• The online Locator and Directory will explain that potential clients should call the facility for information on eligibility.

1 ¨ Yes

0 ¨ No

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

1  Yes

0  No SKIP TO Q.22 (BELOW)

21a. Do you want the availability of treatment at no charge or minimal payment (for example, $1) for eligible clients published in SAMHSA’s online Locator and Directory?

• The online Locator and Directory will explain that potential clients should call the facility for information on eligibility.

1 ¨ Yes

0 ¨ No

*22. Does this facility receive any funding or grants from the Federal Government, or state, county or local governments, to support its substance use treatment programs?

• Do not include Medicare, Medicaid, or federal military insurance. These forms of client payments are included in Q.23.

1 ¨ Yes

0 ¨ No

d ¨ Don’t know

*23. Which of the following types of client payments or insurance are accepted by this facility for substance use treatment?

MARK ALL THAT APPLY

1  No payment accepted (free treatment for ALL clients)

2  Cash or self-payment

3  Medicare

4  Medicaid

5  State-financed health insurance plan other than Medicaid

6  Federal military insurance (e.g., TRICARE)

7  Private health insurance

8  IHS/Tribal/Urban (ITU) funds

9  Other (Specify: _________________________________________________ )

*24. Is this facility a hospital or located in or operated by a hospital?

1  Yes SKIP TO Q.24a (TOP OF NEXT PAGE)

0  No SKIP TO Q.25 (NEXT PAGE)

*24a. What type of hospital?

MARK ONE ONLY

1  General hospital (including VA hospital)

2  Psychiatric hospital

3  Other specialty hospital, for example, alcoholism, maternity, etc.

(Specify: )

SECTION C:

GENERAL INFORMATION

*25. Does this facility operate transitional housing, a halfway house, or a sober home for substance abuse clients at this location, that is, the location listed on the front cover?

1 ¨ Yes

0 ¨ No

*26. 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

HFAP

OTHSTATE_SPEC

OTHSTATE

4  Permitted in designated indoor area(s)

5  Permitted anywhere inside

6  Permitted anywhere without restriction

*27. Is this facility or program licensed, certified, or accredited to provide substance abuse services by any of the following organizations?

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

MARK ALL THAT APPLY

1  State substance abuse agency

2  State mental health department

3  State department of health

4  Hospital licensing authority

5  The Joint Commission

6  Commission on Accreditation of Rehabilitation Facilities (CARF)

7  National Committee for Quality Assurance (NCQA)

8  Council on Accreditation (COA)

9  Healthcare Facilities Accreditation Program (HFAP)

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

(Specify: )

28. If eligible, does this facility want to be listed in SAMHSA’s online Behavioral Health Treatment Services Locator and Substance Abuse Directory? (See inside front cover for eligibility information)

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

• The Directory will be available at https://www.samhsa.gov/data/substance-abuse-facilities-data-nssats

1 ¨ Yes

0 ¨ No SKIP TO Q.29 (BELOW)

28a. Does this facility want the street address and/or mailing address to be listed in SAMHSA’s online Behavioral Health Treatment Services Locator and Substance Abuse Directory?

MARK ALL THAT APPLY

1 ¨ Publish the street address

2 ¨ Publish the mailing address

3 ¨ Do not publish either address

28b. 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

29. Did you answer “yes” to either detoxification in option 2 or substance use treatment in option 3 of question 1?

1  Yes SKIP TO Q.30 (TOP OF NEXT PAGE)

0  No SKIP TO Q.37 (PAGE 14)

SECTION B:

REPORTING CLIENT COUNTS

30. Questions 31 through 36 ask about the number of clients in treatment. If possible, report clients for this facility only. However, we realize that is not always possible. Please indicate whether the clients you report will be for . . .

MARK ONE ONLY

1 ¨ Only this facility SKIP TO Q.31

(TOP OF NEXT COLUMN)

2 ¨ This facility plus others

3 ¨ Another facility will report this facility’s

client counts SKIP TO Q.37 (PAGE 14)

3 0a. How many facilities will be included in your client counts?

1

THIS FACILITY

+ ADDITIONAL FACILITIES

TOTAL FACILITIES^α

^αFor Section B, please include all of these facilities in the client counts that you report in questions 31 through 36.

30b. To avoid double-counting clients, we need to know which facilities are included in your counts. How will you report this information to us?

MARK ONE ONLY

1  By listing the names and location addresses of these additional facilities in the “Additional Facilities Included in Client Counts” section on page 15 of this questionnaire or attaching a sheet of paper to this questionnaire

2  Please call me for a list of the additional facilities included in these counts

HOSPITAL INPATIENT CLIENT COUNTS

31. On March 31, 2021, did any patients receive HOSPITAL INPATIENT substance abuse services at this facility?

1 ¨ Yes

0 ¨ No SKIP TO Q.32 (NEXT PAGE)

31a. On March 31, 2021, how many patients received the following HOSPITAL INPATIENT substance abuse services at this facility?

• count a patient in one service only, even if the patient received both services.

• do not count family members, friends, or other non‑treatment patients.

ENTER A NUMBER FOR EACH

(IF NONE, ENTER “0”)

1. Hospital inpatient detoxification _____________

(similar to ASAM Levels IV-D

and III.7-D, medically managed or

monitored inpatient detoxification)

2. Hospital inpatient treatment _____________

(similar to ASAM Levels IV

and III.7, medically managed or

monitored intensive inpatient treatment)

HOSPITAL INPATIENT TOTAL BOX

NOTE: ASAM is the American Society of Addiction Medicine.

For more information on ASAM please go to https://info.nssats.com.

31b. How many of the patients from the HOSPITAL INPATIENT TOTAL BOX were under the age of 18?

ENTER A NUMBER

(IF NONE, ENTER “0”)

Number under age 18 _______________

31c. How many of the patients from the HOSPITAL INPATIENT TOTAL BOX received:

• Include patients who received these drugs for detoxification, maintenance, or relapse prevention for opioid use disorder.

ENTER A NUMBER FOR EACH

(IF NONE, ENTER “0”)

1. Methadone dispensed at this

facility for opioid use disorder _______________

2. Buprenorphine dispensed or

prescribed at this facility

for opioid use disorder _______________

3. Naltrexone administered

at this facility for

opioid use disorder _______________

31d. How many of the patients from the HOSPITAL INPATIENT TOTAL BOX received:

• Include patients who received these medications for alcohol use disorder.

ENTER A NUMBER FOR EACH

(IF NONE, ENTER “0”)

1. Disulfiram (Antabuse®) dispensed

or prescribed at this facility

for alcohol use disorder _______________

2. Naltrexone dispensed

or prescribed at this facility

for alcohol use disorder _______________

3. Acamprosate (Campral®) dispensed

or prescribed at this facility

for alcohol use disorder _______________

31e. On March 31, 2021, how many hospital inpatient beds were specifically designated for substance use treatment?

ENTER A NUMBER

(IF NONE, ENTER “0”)

Number of beds _______________

RESIDENTIAL (NON-HOSPITAL)
CLIENT COUNTS

32. On March 31, 2021, did any clients receive RESIDENTIAL (non‑hospital) substance abuse services at this facility?

1 ¨ Yes

0 ¨ No SKIP TO Q.33 (TOP OF NEXT PAGE)

32a. On March 31, 2021, how many clients received the following RESIDENTIAL substance abuse services at this facility?

• COUNT a client in one service only, even if the client received multiple services.

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

ENTER A NUMBER FOR EACH

(IF NONE, ENTER “0”)

1. Residential detoxification

(similar to ASAM Level III.2-D,

clinically managed residential

detoxification or social detoxification)

2. Residential short-term treatment

(similar to ASAM Level III.5,

clinically managed high-intensity

residential treatment, typically

30 days or less)

3. Residential long-term treatment

(similar to ASAM Levels III.3 and III.1, clinically managed medium- or low-intensity residential treatment, typically more than 30 days)

RESIDENTIAL TOTAL BOX

32b. How many of the clients from the RESIDENTIAL TOTAL BOX were under the age of 18?

ENTER A NUMBER

(IF NONE, ENTER “0”)

Number under age 18 _______________

32c. How many of the clients from the RESIDENTIAL TOTAL BOX received:

• Include clients who received these drugs for detoxification, maintenance, or relapse prevention for opioid use disorder.

ENTER A NUMBER FOR EACH

(IF NONE, ENTER “0”)

1. Methadone dispensed at this
facility for opioid use disorder _______________

2. Buprenorphine dispensed or

prescribed at this facility

for opioid use disorder _______________

3. Naltrexone administered

at this facility for

opioid use disorder _______________

32d. How many of the clients from the RESIDENTIAL TOTAL BOX received:

• Include clients who received these medications for alcohol use disorder.

ENTER A NUMBER FOR EACH

(IF NONE, ENTER “0”)

1. Disulfiram (Antabuse®) dispensed

or prescribed at this facility

for alcohol use disorder _______________

2. Naltrexone dispensed

or prescribed at this facility

for alcohol use disorder _______________

3. Acamprosate (Campral®) dispensed

or prescribed at this facility

for alcohol use disorder _______________

32e. On March 31, 2021, how many residential beds were specifically designated for substance use treatment?

ENTER A NUMBER

(IF NONE, ENTER “0”)

Number of beds _______________

OUTPATIENT CLIENT COUNTS

33. During the month of March 2021, did any clients receive OUTPATIENT substance abuse services at this facility?

1 ¨ Yes

0 ¨ No SKIP TO Q.34 (TOP OF NEXT PAGE)

33a. As of March 31, 2021, how many active clients were receiving each of the following OUTPATIENT substance abuse services at this facility?



An active client is a client who received treatment in March AND was still enrolled in treatment on March 31, 2021.

• count a client in one service only, even if the client received multiple services.

• do not count family members, friends, or other non‑treatment clients.

ENTER A NUMBER FOR EACH

(IF NONE, ENTER “0”)

1. Outpatient detoxification _________

(similar to ASAM

Levels I-D and II-D,

ambulatory detoxification)

2. Outpatient methadone/ _________

buprenorphine maintenance

or naltrexone treatment

(count methadone/buprenorphine/

naltrexone clients on this line only)

3. Outpatient day treatment _________

or partial hospitalization

(similar to ASAM Level II.5,

20 or more hours per week)

4. Intensive outpatient treatment _________

(similar to ASAM Level II.1,

9 or more hours per week)

5. Regular outpatient treatment _________

(similar to ASAM Level I,

outpatient treatment,

non-intensive)

OUTPATIENT TOTAL BOX

33b. How many of the clients from the OUTPATIENT TOTAL BOX were under the age of 18?

ENTER A NUMBER

(IF NONE, ENTER “0”)

Number under age 18 _______________

33c. How many of the clients from the OUTPATIENT TOTAL BOX received:

• Include clients who received these drugs for detoxification, maintenance, or relapse prevention for opioid use disorder.

ENTER A NUMBER FOR EACH

(IF NONE, ENTER “0”)

1. Methadone dispensed at this

facility for opioid use disorder _______________

2. Buprenorphine dispensed or

prescribed at this facility

for opioid use disorder _______________

3. Naltrexone administered

at this facility for

opioid use disorder _______________

33d. How many of the clients from the OUTPATIENT TOTAL BOX received:

• Include clients who received these medications for alcohol use disorder.

ENTER A NUMBER FOR EACH

(IF NONE, ENTER “0”)

1. Disulfiram (Antabuse®) dispensed

or prescribed at this facility

for alcohol use disorder _______________

2. Naltrexone dispensed

or prescribed at this facility

for alcohol use disorder _______________

3. Acamprosate (Campral®) dispensed

or prescribed at this facility

for alcohol use disorder _______________

all substance abuse treatment settings

Including Hospital Inpatient,

Residential (non‑hospital) and/or Outpatient

34. This question asks you to categorize the substance use treatment clients at this facility into three groups: clients in treatment for (1) abuse of both alcohol and substances other than alcohol; (2) abuse only of alcohol; or (3) abuse only of substances other than alcohol.

Enter the percent of clients on March 31, 2021, who were in each of these three groups:

Clients in treatment for abuse of:

1. BOTH alcohol and substances other than alcohol ___________%

2. ONLY alcohol ___________%

3. ONLY substances other than alcohol ___________%

TOTAL

100 %

35. Approximately what percent of the substance use treatment clients enrolled at this facility on March 31, 2021, had a diagnosed co-occurring mental and substance use disorder?

PERCENT OF CLIENTS (IF NONE, ENTER “0”)

%

36. Using the most recent 12-month period for which you have data, approximately how many substance use treatment ADMISSIONS did this facility have?

• OUTPATIENT CLIENTS: Count admissions into treatment, not individual treatment visits. Consider an admission to be the initiation of a treatment program or course of treatment. Count any re‑admission as an admission.

• IF THIS IS A MENTAL HEALTH FACILITY: Count all admissions in which clients received substance use treatment, even if substance abuse was their secondary diagnosis.

NUMBER OF SUBSTANCE USE TREATMENT ADMISSIONS IN A 12-MONTH PERIOD

37. 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:

ADDITIONAL FACILITIES INCLUDED IN CLIENT COUNTS
	Complete this section if you reported clients for this facility plus other facilities, as indicated in Question 30. For each additional facility, please mark if that facility offers hospital inpatient, residential and/or outpatient substance abuse services at that location.

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

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 Drug and Alcohol Abuse Treatment Programs, and other publicly-available listings. Responses to non‑asterisked questions will be published with no direct link to individual treatment facilities.

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

P.O. Box 2393

Princeton, NJ 08543-2393

9

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 40 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-A, Rockville, Maryland 20857.