N-SUMHSS 2021 Ques N-SUMHSS 2021 Questionnaire

National Substance Use and Mental Health Services Survey (N-SUMHSS)

Attachment B1_N-SUMHSS 2021 Questionnaire 060320

OMB: 0930-0386

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Attachment B1: 2021 N-SUMHSS Questionnaire

NATIONAL SUBSTANCE USE AND MENTAL HEALTH SERVICES SURVEY (N-SUMHSS)

  1. What type of treatment does this facility at this location, provide?

Primarily Substance use treatment services

Primarily Mental health services

Mix of mental health and substance use treatment services

No treatment for either substance use or mental health is provided at this location

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

Yes

No

MODULE A: SUBSTANCE USE TREATMENT FACILITIES

*A1. Which of the following substance use treatment 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

Intake, assessment, or referral

Detoxification (medical withdrawal)

Substance use disorder treatment

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

Treatment for co-occurring substance use

plus either serious mental illness

(SMI) in adults and/or serious emotional

disturbance (SED) in children

Any other substance use treatment

services (such as 12 step meeting facilitation,

naloxone prescriptions, etc.)









A1a. To which of the following clients does this facility, at this location, offer mental 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

Substance use treatment clients

Clients other than substance use treatment clients

No clients are offered mental health treatment services at this facility





*A2. Does this facility detoxify (medical withdrawal) clients from . . .

MARK ALL THAT APPLY

Alcohol

Benzodiazepines

Cocaine

Methamphetamines

Opioids

Other(s) (Specify:_________________________________________)



*A2a. Does this facility routinely use medication during detoxification (medical withdrawal)?

Yes

No


A3. Is this facility a solo practice; that is, an office with only one independent practitioner or counselor?

Yes

No

*A4. Does this facility offer HOSPITAL INPATIENT substance use treatment services at this location; that is, the location listed on the front cover?

Yes SKIP TO A4a (BELOW)

No SKIP TO A5 (BELOW)









*A4a. Which of the following INPATIENT services are offered at this facility?

MARK “YES” OR “NO” FOR EACH

YES NO

Inpatient detoxification (medical withdrawal) ¨ ¨

(medically managed or monitored inpatient detoxification)

Inpatient treatment ¨ ¨

(medically managed or monitored intensive inpatient treatment))

*A5. Does this facility offer RESIDENTIAL (non‑hospital) substance use treatment services at this location, that is, the location listed on the front cover?

Yes SKIP TO A5a (BELOW)

No SKIP TO A6 (BELOW)


*A5a. Which of the following RESIDENTIAL services are offered at this facility?

MARK “YES” OR “NO” FOR EACH

YES NO

Residential detoxification (medical withdrawal) ¨ ¨

(clinically managed residential detoxification or social detoxification)

Residential short-term treatment ¨ ¨

(clinically managed high-intensity residential treatment, typically 30 days or less)

Residential long-term treatment ¨ ¨

(clinically managed medium- or low-intensity residential treatment)



*A6. Does this facility offer OUTPATIENT substance use treatment services at this location; that is, the location listed on the front cover?

Yes SKIP TO A6a (BELOW)

No SKIP TO A7 (BELOW)

*A6a. Which of the following OUTPATIENT services are offered at this facility?

MARK “YES” OR “NO” FOR EACH

YES NO

Outpatient detoxification ¨ ¨

(ambulatory detoxification)

Outpatient methadone/
buprenorphine maintenance or
naltrexone treatment ¨ ¨

Outpatient day treatment

or partial hospitalization ¨ ¨

(20 or more hours per week)

Intensive outpatient treatment ¨ ¨

(9 or more hours per week)

Regular outpatient treatment ¨ ¨

(outpatient treatment, non-intensive)

*A7. 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

Screening for substance use

Screening for mental disorders

Comprehensive substance use assessment or diagnosis

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

Complete medical history and physical exam performed by a healthcare practitioner

Screening for tobacco use

Outreach to persons in the community who may need treatment

Interim services for clients when immediate admission is not possible

Professional interventionist/educational consultant

None of the assessment and pre‑treatment services above are offered at this facility

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

Drug and alcohol oral fluid testing

Breathalyzer or other blood alcohol testing

Drug or alcohol urine screening

Testing for Hepatitis B (HBV)

Testing for Hepatitis C (HCV)

HIV testing

STD testing

TB screening

Testing for metabolic syndrome (weight, abdominal girth, BP, glucose, Hgb A1C, cholesterol, triglycerides)

None of the testing services above are offered at this facility

Medical Services

Hepatitis A (HAV) vaccination

Hepatitis B (HBV) vaccination

None of the medical services above are offered at this facility

Transitional Services

Discharge planning

Aftercare/continuing care

Naloxone and overdose education

Outcome follow-up after discharge

None of the transitional services above are offered at this facility

Recovery Support Services

Mentoring/peer support

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

Assistance in locating housing for clients

Employment counseling or training for clients

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

Recovery coach

None of the recovery support services above are offered at this facility

Education and Counseling Services

HIV or AIDS education, counseling, or support

Hepatitis education, counseling, or support

Health education other than HIV/AIDS or Hepatitis

Substance use disorder education

Smoking/tobacco cessation counseling

Individual counseling

Group counseling

Family counseling

Marital/couples counseling

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

None of the education and counseling services above are offered at this facility

Ancillary Services

Case management services

Integrated primary care services

Social skills development

Child care for clients’ children

Domestic violence services, including family or partner violence services, for physical, sexual, or emotional abuse

Early intervention for HIV

Transportation assistance to treatment

Mental health services

Suicide prevention services

Acupuncture

Residential beds for clients’ children

None of the ancillary services above are offered at this facility

Other Services

Treatment for gambling disorder

Treatment for other addiction disorder (non‑substance use disorder)

None of the other services above are offered at this facility

Pharmacotherapies

Disulfiram

Naltrexone (oral)

Naltrexone (extended-release, injectable)

Acamprosate

Nicotine replacement

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

Medications for mental disorders

Methadone

Buprenorphine/naloxone

Buprenorphine without naloxone

Buprenorphine sub-dermal implant

Buprenorphine (extended-release, injectable)

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

Medications for pre-exposure prophylaxis (PrEp: e.g. emtricitabine and tenofovir disoproxil fumarate combination, and emtricitabine and tenofovir alafenamide combination)

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

Lofexidine

Clonidine

Medications for other medical conditions __________________________________________

None of the pharmacotherapy services above are offered at this facility































*A8. 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 products and/or naltrexone for the treatment of opioid use disorder. For this question, MAT refers to any or all of these medications unless specified otherwise.

MARK ALL THAT APPLY

Shape16 Shape15

SKIP TO A8a


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.)

Shape17

This facility prescribes naltrexone to treat opioid use disorder. Naltrexone use is authorized through any medical staff with prescribing privileges.

This facility utilizes prescribers of buprenorphine to treat opioid use disorder. Buprenorphine use is authorized through a DATA 2000 waivered physician, physician assistant, or nurse practitioner.

This facility is a federally-certified Opioid Treatment Program (OTP). (Most OTPs administer/dispense methadone; some only use buprenorphine, some provide all FDA-approved medication treatments for opioid use disorder.)

Shape18


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.



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

Shape20 Shape19

SKIP TO A9


This facility does not treat opioid use disorder.



*A8a. For those clients using MAT, but whose medications originate from or are prescribed by another entity, the clients obtain their prescriptions from …

MARK ALL THAT APPLY

A prescribing entity in our network

A prescribing entity with which our facility has a business, contractual, or formal referral relationship

A prescribing entity with which our facility has no formal relationship

*A8b. Does this facility serve only opioid use disorder clients?

Yes

No

*A8c. Which of the following medication services does this program provide for opioid use disorder?

MARK ALL THAT APPLY

Maintenance services with methadone or buprenorphine

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

Detoxification (medical withdrawal) from opioids of abuse with methadone or buprenorphine

Detoxification (medical withdrawal) from opioids of abuse with lofexidine or clonidine

Relapse prevention with naltrexone

Other (e.g. Overdose risk reduction with Naloxone, Specify opioid use disorder service and pharmacotherapy used: ______________________________________________________ )

None of the medication services for opioid use disorder above are offered at this facility



*A9. 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

This facility accepts clients using MAT for alcohol use disorder, but the medications originate from or are prescribed by another entity. SKIP TO A9a

This facility administers/prescribes disulfiram for alcohol use disorder. SKIP TO A9a

This facility administers/prescribes naltrexone for alcohol use disorder. SKIP TO A9a

This facility administers/prescribes acamprosate for alcohol use disorder. SKIP TO A9a

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 A9b

This facility does not treat alcohol use disorder. SKIP TO A10

*A9a. For those clients using MAT, but whose medications originate from or are prescribed by another entity, the clients obtain their prescriptions from …

MARK ALL THAT APPLY

A prescribing entity in our network

A prescribing entity with which our facility has a business, contractual, or formal referral relationship

A prescribing entity with which our facility has no formal relationship

*A9b. Does this facility serve only alcohol use disorder clients?

Yes

No

*A10. Which of the following clinical/therapeutic approaches listed below are used frequently at this facility?


Mark ALL THAT APPLY for Each APPROACH

CLINICAL/THERAPEUTIC APPROACHES

Opioid Use Disorder

Other substances

Substance use disorder counseling

12-step facilitation

Brief intervention

Cognitive behavioral therapy

Contingency management/motivational incentives

Motivational interviewing

Trauma-related counseling

Anger management

Matrix Model

Community reinforcement plus vouchers

Relapse prevention

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

Other treatment approach (Specify:_________________________ )

None of the clinical/therapeutic approaches above are offered at this facility



*A11. Does this facility, at this location, offer a specially designed program or group intended exclusively for DUI/DWI or other drunk driver offenders?

Yes SKIP TO A11a

No SKIP TO A12

*A11a. Does this facility serve only DUI/DWI clients?

Yes

No


A12. Does this facility provide treatment services for…?

Marijuana

Stimulants

Other substance(s) (Specify: _________________________________________________ )

*A13. 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.

Yes

No

*A14. Does this facility provide substance use treatment services in a language other than English at this location?

Yes SKIP TO A14a

No SKIP TO A15

A14a. At this facility, who provides substance use treatment services in a language other than English?

MARK ONE ONLY

Staff counselor who speaks a language other than English SKIP TO A14a1

On-call interpreter (in person or by phone) brought in when needed SKIP TO A14a1

BOTH staff counselor and on-call interpreter SKIP TO A15

*A14a1. Do staff counselors provide substance use treatment in Spanish at this facility?

Yes SKIP TO A14a2

No SKIP TO A14b

A14a2. Do staff counselors at this facility provide substance use treatment in any other languages?

Yes SKIP TO A14b

No SKIP TO A15

*A14b. 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:

Hopi

Lakota

Navajo

Ojibwa

Yupik

Other American Indian or Alaska Native language

(Specify: )

Other Languages:

Arabic

Any Chinese language

Creole

Farsi

French

German

Greek

Hebrew

Hindi

Hmong

Italian

Japanese

Korean

Polish

Portuguese

Russian

Tagalog

Vietnamese

Any other language

(Specify: )



*A15. Individuals seeking substance use treatment can vary by age, sex 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








Female

Yes

No

| | |

YEARS

No minimum age

| | |

YEARS

No maximum age








Male

Yes

No

| | |

YEARS

No minimum age

| | |

YEARS

No maximum age

*A15. 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

Adolescents

Young adults

Adult women

Pregnant/postpartum women

Adult men

Seniors or older adults

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

Veterans

Active duty military

Members of military families

Criminal justice clients (other than DUI/DWI)

Clients with co-occurring mental and substance use disorders

Clients with co-occurring pain and substance use disorders

Clients with HIV or AIDS

Clients who have experienced sexual abuse

Clients who have experienced intimate partner violence, domestic violence

Clients who have experienced trauma

Specifically tailored programs or groups for any other types of clients

(Specify: )

Specifically tailored programs or groups for any other types of clients

(Specify:___________________________)

No specifically tailored programs or groups are offered



*A16. 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 the following question.

¨ Yes

¨ No

¨ Don’t know

*A17. Which of the following types of client payments or insurance are accepted by this facility for substance use treatment?

MARK ALL THAT APPLY

No payment accepted (free treatment for ALL clients)

Cash or self-payment

Medicare

Medicaid

State-financed health insurance plan other than Medicaid

Federal military insurance (e.g., TRICARE)

Private health insurance

SAMHSA funding/block grants

IHS/Tribal/Urban (ITU) funds

Other (Specify: _________________________________________________ )

*A18. Is this facility a hospital or located in or operated by a hospital?

Yes SKIP TO A18a

No SKIP TO A19



*A18a. What type of hospital?

MARK ONE ONLY

General hospital (including VA hospital)

Psychiatric hospital

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

(Specify: )



A19. Does this facility operate as a skilled nursing facility (SNF) that provides services for substance use disorders?

Yes

No


*A20. Does this facility operate transitional housing, a halfway house, or a sober home for substance use clients at this location; that is, the location listed on the front cover of the paper survey?

¨ Yes

¨ No


*A21. Is this facility or program licensed, certified, or accredited to provide substance use treatment 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

State substance use treatment agency

State mental health department

State department of health

Hospital licensing authority

The Joint Commission

Commission on Accreditation of Rehabilitation Facilities (CARF)

National Committee for Quality Assurance (NCQA)

Council on Accreditation (COA)

Healthcare Facilities Accreditation Program (HFAP)

SAMHSA certification for opioid treatment program (OTP)

Drug Enforcement Agency (DEA)

Other national organization or federal, state, or local agency

(Specify: )

This facility is not licensed, certified, or accredited to provide substance use services by any of these organizations















MODULE B: MENTAL DISORDERS TREATMENT FACILITIES



B1. Does this treatment facility, at this location, offer:

MARK “YES” OR “NO” FOR EACH

YES NO

Mental health intake

Mental health diagnostic evaluation

Mental health information and/or

referral (also includes emergency programs

that provide services in person or by telephone)

Mental health treatment

(interventions such as therapy or psychotropic

medication that treat a person’s mental disorder or

condition, reduce symptoms, and improve

behavioral functioning and outcomes)

Treatment for co-occurring

disorders plus either serious mental illness

(SMI) in adults and/or serious emotional disturbance

(SED) in children

Substance use treatment

Administrative or operational services

for mental health treatment facilities

*B2. 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

24-hour hospital inpatient

24-hour residential

Partial hospitalization/day treatment

Outpatient





*B3. Which ONE category BEST describes this facility, at this location?

        • For definitions of facility types, go to: INSERT LINK

Shape21 MARK ONE ONLY

Psychiatric hospital

Separate inpatient psychiatric unit of a general hospital (consider this psychiatric unit as the relevant “facility” for the purpose of this survey)

Shape22

SKIP TO B5

State hospital

Residential treatment center for children

Residential treatment center for adults

Other type of residential treatment facility

Veterans Affairs Medical Center (VAMC) or other VA health care facility

Shape23

Community Mental Health Center (CMHC)

Certified Community Behavioral Health Clinic (CCBHC)

Partial hospitalization/day treatment facility

Shape24

SKIP TO B4

Outpatient mental health facility

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

Other (Specify:_____________________________)



B4. Is this facility either a solo or a small group practice?

Yes SKIP TO B4a

No SKIP TO B5

*B4a. 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.

Yes

No

B5. Does this facility, at this location, provide any of the following services?

MARK ALL THAT APPLY

Assisted living or nursing home care

Group homes

Clubhouse services

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

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

None of these services are offered at this facility

*B6. Which of these treatment modalities for mental disorders are offered at this facility, at this location?

        • For definitions of treatment modalities, go to: INSERT LINK

MARK ALL THAT APPLY

Individual psychotherapy

Couples/family therapy

Group therapy

Cognitive behavioral therapy

Dialectical behavior therapy

Cognitive remediation therapy

Integrated mental and substance use disorder treatment

Activity therapy (for example, art therapy)

Electroconvulsive therapy

Transcranial Magnetic Stimulation (TMS)

Ketamine Infusion Therapy (KIT)

Eye Movement Desensitization and Reprocessing (EMDR) therapy

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

Abnormal Involuntary Movement Scale (AIMS) Test

Other(s) (Specify: _____________________________________________)

None of these mental health treatment modalities are offered at this facility



*B7. Does this facility offer the use of antipsychotics for the treatment of serious mental illness (SMI)?

Yes SKIP TO B7a

No SKIP TO B8



*B7a. 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

Not Used At This Facility

Oral

Injectable

Long-acting Injectable

Rectal

Topical

Chlorpromazine

Droperidol

Fluphenazine

Haloperidol

Loxapine

Perphenazine

Pimozide

Thiothixene

Thioridazine

Trifluoperazine

Other first-generation antipsychotics (Specify:___________________________)




Mark ALL THAT APPLY for Each MEDICATION

SECOND-GENERATION ANTIPSYCHOTIC

Not Used At This Facility

Oral

Injectable

Long-acting Injectable

Rectal

Topical

Aripiprazole

Asenapine

Brexpiprazole

Cariprazine

Clozapine

IIoperidone

Lurasidone

Olanzapine

Olanzapine/Fluoxetine combination

Paliperidone

Quetiapine

Risperidone

Ziprasidone

Other second-generation antipsychotics (Specify: ­­­­­­­­­­­­­­____________________________­

­­­­­­­­­­­­­­­­­­­­­­­_______________________________)



*B8. Which of these services and practices are offered at this facility, at this location?

        • For definitions, go to: INSERT LINK



MARK ALL THAT APPLY

Assertive community treatment (ACT)

Intensive case management (ICM)

Case management (CM)

Court-ordered treatment

Assisted Outpatient Treatment (AOT)

Chronic disease/illness management (CDM)

Illness management and recovery (IMR)

Integrated primary care services

Diet and exercise counseling

Family psychoeducation

Education services

Housing services

Supported housing

Psychosocial rehabilitation services

Vocational rehabilitation services

Supported employment

Therapeutic foster care

Legal advocacy

Psychiatric emergency walk-in services

Suicide prevention services

Peer support services

Testing for Hepatitis B (HBV)

Testing for Hepatitis C (HCV)

Laboratory tests (for example, WBC for clozapine therapy, Lithium levels, CBZ levels, valproate levels)

Metabolic syndrome monitoring (weight, abdominal girth, BP, glucose, Hgb A1C, cholesterol, triglycerides)

HIV testing

STD testing

TB screening

Screening for tobacco use

Smoking/vaping/tobacco cessation counseling

Nicotine replacement therapy

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

Other(s) (Specify: ___________________)

None of these services and practices are offered at this facility



B9. Which of the following services are provided to clients with co-occurring mental health and substance use at this facility?

MARK ALL THAT APPLY

Detoxification (medical withdrawal)

Medication-assisted treatment for alcohol use disorder (for example, disulfiram, camprosate)

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

Individual counseling

Group counseling

12-Step groups

Case management

Other

None of these services are offered at this facility

*B10. What age groups are accepted for treatment at this facility?

        • If any of the ages that you accept fall within a category below, mark YES to that category.

MARK “YES” OR “NO” FOR EACH

YES NO

Young children (0-5)

Children (6-12)

Adolescents (13-17)

Young adults (18-25)

Adults (26-64)

Older adults (65 or older)







*B11. 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)

Young adults

Persons 18 and older with serious mental illness (SMI)

Older adults

Persons with Alzheimer’s disease or dementia

Persons with co-occurring mental and substance use disorders

Persons with eating disorders

Persons experiencing first-episode psychosis

Persons who have experienced intimate partner violence, domestic violence

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

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

Persons with traumatic brain injury (TBI)

Veterans

Active duty military

Members of military families

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

Forensic clients (referred from the court/judicial system)

Persons with HIV or AIDS

Other special program or group (Specify: ____________________________________________)

Other special program or group (Specify:

____________________________________________)

No dedicated or exclusively designed programs or groups are offered at this facility



*B12. Does this facility offer a crisis intervention team that handles acute mental health issues at this facility and/or off-site?

Yes

No

*B13. Does this facility offer services for psychiatric emergencies onsite?

Yes

No

*B14. Does this facility offer mobile/off-site psychiatric crisis services?

Yes

No

*B15. 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 a staff counselor or an on‑call interpreter provides this service.

Yes

No

*B16. Does this facility provide mental health treatment services in a language other than English at this location?

Yes SKIP TO B16a

No SKIP TO B17

B16a. At this facility, who provides mental treatment services in a language other than English?

MARK ONE ONLY

Staff counselor who speaks a language other than English SKIP TO B16a1

On-call interpreter (in person or by phone) brought in when needed SKIP TO B17

BOTH staff counselor and on-call interpreter SKIP TO B16a1

*B16a1. Do staff counselors provide mental health treatment in Spanish at this facility?

Yes

No

B16a2. Do staff counselors at this facility provide mental health treatment in any other languages?

Yes SKIP TO B16b

No SKIP TO B17



*B16b. In what other languages do staff counselors provide mental health treatment at this facility?

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

MARK ALL THAT APPLY

American Indian or Alaska Native:

Hopi

Lakota

Navajo

Ojibwa

Yupik

Other American Indian or Alaska Native language

(Specify: )

Other Languages:

Arabic

Any Chinese language

Creole

Farsi

French

German

Greek

Hebrew

Hindi

Hmong

Italian

Japanese

Korean

Polish

Portuguese

Russian

Tagalog

Vietnamese

Any other language

(Specify: )


B17. Which of these quality improvement practices are part of this facility’s standard operating procedures?

MARK “YES” OR “NO” FOR EACH

YES NO

Continuing education requirements for professional staff

Regularly scheduled case review with a supervisor

Regularly scheduled case review by an appointed quality review committee

Client outcome follow-up after discharge

Continuous quality improvement processes

Periodic client satisfaction surveys

Clinical provider peer review (CPPR)

Root cause analysis (RCA)









B18. In the 12-month period beginning April 1, 2020, and ending March 31, 2021, have staff at this facility used:




Mark ALL THAT APPLY


Not Used At This Facility

Chemical

Physical

Seclusion

Restraint



B18a. Does this facility have any policies in place to minimize the use of seclusion or restraint?

Yes

No

*B19. 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

Cash or self-payment

Private health insurance

Medicare

Medicaid

State-financed health insurance plan other than Medicaid

State mental health agency (or equivalent) funds

State welfare or child and family services agency funds

State corrections or juvenile justice agency funds

State education agency funds

Other state government funds

County or local government funds

Community Service Block Grants

Community Mental Health Block Grants

Federal grants (specify:______________________________)

Federal military insurance (such as TRICARE)

  • U.S. Department of Veterans Affairs funds

IHS/Tribal/Urban (ITU) funds

Private or Community foundation

Other (Specify: ____________________________________)

B20. 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

State mental health authority

State substance use treatment agency

State department of health

State or local Department of Family and Children’s Services

Hospital licensing authority

The Joint Commission

Commission on Accreditation of Rehabilitation Facilities (CARF)

Council on Accreditation (COA)

Centers for Medicare and Medicaid Services (CMS)

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

(Specify: ___________________________)

This facility does not have licensing, certification, or accreditation from any of these organizations



MODULE C: FOR ALL TREATMENT FACILITIES

*C1. 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:
          INSERT LINK

Yes

No

Don’t know







*C2. Is this facility operated by . . .

MARK ONE ONLY

A private for-profit organization SKIP TO C3

A private non-profit organization SKIP TO C3

Shape32

State government

Shape33

SKIP TO C2a

Local, county, or community government

Tribal government

Federal Government

*C2a. Which Federal Government agency?

MARK ONE ONLY

Department of Veterans Affairs

Department of Defense

Indian Health Service

Other (Specify:______________________)

C3. Is this facility affiliated with a religious (or faith-based) organization?

Yes

No

*C4. Which of the following statements BEST describes this facility’s smoking policy for clients?

MARK ONE ONLY

Not permitted to smoke anywhere outside or within any building

Permitted in designated outdoor area(s)

Permitted anywhere outside

Shape34

OTHSTATE_SPEC

Permitted in designated indoor area(s)

Permitted anywhere inside

Permitted anywhere without restriction




*C5. Which of the following statements BEST describes this facility’s vaping policy for clients?

MARK ONE ONLY

Not permitted to vape anywhere outside or within any building

Permitted in designated outdoor area(s)

Permitted anywhere outside

Shape35

OTHSTATE_SPEC

Permitted in designated indoor area(s)

Permitted anywhere inside

Permitted anywhere without restriction


*C6. Does this facility use a sliding fee scale?

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

Yes SKIP TO C6a

No SKIP TO C7

C6a. Do you want the availability of a sliding fee scale published in SAMHSA’s online Behavioral Health Treatment Services Locator and Directory?

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

¨ Yes

¨ No

*C7. Does this facility offer treatment at no charge or minimal payment (for example, $1) to clients who cannot afford to pay?

Yes SKIP TO C7a

No SKIP TO C8

C7a. 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 and Directory?

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

¨ Yes

¨ No

C8. If eligible, does this facility want to be listed in SAMHSA’s online Behavioral Health Treatment Services Locator and Directory? (See inside front cover for eligibility information)

        • The Behavioral Health Treatment Services Locator can be found at INSERT LINK

        • The Directory will be available at INSERT LINK

¨ Yes SKIP TO C8a

¨ No SKIP TO C9

C8a. Does this facility want the street address and/or mailing address to be listed in SAMHSA’s online Behavioral Health Treatment Services Locator and Directory?

MARK ALL THAT APPLY

¨ Publish the street address

¨ Publish the mailing address

¨ Do not publish either address


C8b. 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.

¨ Yes

¨ No



C9. Is this facility part of an organization with multiple facilities or sites that provide substance use or mental disorder treatment?

¨ Yes

¨ No

C10. What is the name, address, and phone number of the facility that is the parent, or lead site (HQ), of the organization?

Name:

Address:

Phone Number: (_____) -



MODULE D: CLIENT COUNTS SECTION



D1. The next set of questions ask about the number of clients in treatment. 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

¨ Only this facility SKIP TO D4

¨ This facility plus others SKIP TO D2

¨ Another facility will report this facility’s client counts SKIP TO D10 or E1

D2. How many facilities will be included in your client counts?


Shape36

1

THIS FACILITY

Shape38 Shape37 + ADDITIONAL FACILITIES

Shape39

TOTAL FACILITIESα

αFor this section, please include all of these facilities in the client counts that you will report in the following questions.



D3. 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

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

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



SUBSTANCE USE TREATMENT COUNTS

HOSPITAL INPATIENT CLIENT COUNTS




D4. On March 31, 2021, did any patients receive INPATIENT substance use disorder treatment services at this facility?

¨ Yes SKIP TO D4a

¨ No SKIP TO D5


D4a. On March 31, 2021, how many patients received the following HOSPITAL INPATIENT substance use disorder treatment 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”)

Inpatient detoxification (medical withdrawal) _____________

(medically managed or monitored

inpatient detoxification)

Inpatient treatment _____________

(medically managed or monitored

intensive inpatient treatment)


HOSPITAL INPATIENT

TOTAL BOX




D4b. 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 _______________

D4c. How many of the patients from the HOSPITAL INPATIENT TOTAL BOX received:

  • Include patients who received these drugs for detoxification (medical withdrawal), maintenance, or relapse prevention treatment for opioid use disorder.

ENTER A NUMBER FOR EACH

(IF NONE, ENTER “0”)

Methadone dispensed at this

facility for opioid use disorder _______________

Buprenorphine products dispensed or

prescribed at this facility

for opioid use disorder _______________

Naltrexone administered

at this facility for

opioid use disorder _______________



D4d. 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”)

Disulfiram) dispensed

or prescribed at this facility

for alcohol use disorder _______________

Naltrexone dispensed

or prescribed at this facility

for alcohol use disorder _______________

Acamprosate dispensed

or prescribed at this facility

for alcohol use disorder _______________

D4e. On March 31, 2021, how many hospital inpatient beds were specifically designated for substance use disorder treatment?

ENTER A NUMBER

(IF NONE, ENTER “0”)

Number of beds _______________



RESIDENTIAL (NON-HOSPITAL)
CLIENT COUNTS

D5. On March 31, 2021, did any clients receive RESIDENTIAL (non‑hospital) substance use disorder treatment services at this facility?

¨ Yes SKIP TO D5a

¨ No SKIP TO D6

D5a. On March 31, 2021, how many clients received the following RESIDENTIAL substance use disorder treatment 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”)

Residential detoxification (medical withdrawal) ___________

(clinically managed residential

detoxification or social detoxification)

Residential short-term treatment

(clinically managed high-intensity

residential treatment, typically

30 days or less)

Residential long-term treatment

(clinically managed medium- or low-intensity residential treatment, typically more than 30 days)

RESIDENTIAL

TOTAL BOX


D5b. 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 _______________

D5c. 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”)

Methadone dispensed at this
facility for opioid use disorder
_______________

Buprenorphine products dispensed or

prescribed at this facility

for opioid use disorder _______________

Naltrexone administered

at this facility for

opioid use disorder _______________

D5d. 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”)

Disulfiram dispensed

or prescribed at this facility

for alcohol use disorder _______________


Naltrexone dispensed

or prescribed at this facility

for alcohol use disorder _______________


Acamprosate dispensed

or prescribed at this facility

for alcohol use disorder _______________

D5e. On March 31, 2021, how many residential beds were specifically designated for substance use disorder treatment?

ENTER A NUMBER

(IF NONE, ENTER “0”)

Number of beds _______________

OUTPATIENT CLIENT COUNTS

D6. During the month of March 2021, did any clients receive OUTPATIENT substance use disorder treatment services at this facility?

¨ Yes SKIP TO D6a

¨ No SKIP TO D7

D6a. As of March 31, 2021, how many active clients were receiving each of the following OUTPATIENT substance use disorder treatment services at this facility?

Shape40

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”)

Outpatient detoxification (medical withdrawal) _________

(ambulatory detoxification)

Outpatient methadone/ _________

buprenorphine maintenance

or naltrexone treatment

(count methadone/buprenorphine/

naltrexone clients on this line only)

Outpatient day treatment _________

or partial hospitalization

(20 or more hours per week)

Intensive outpatient treatment _________

(9 or more hours per week)

Regular outpatient treatment _________

(outpatient treatment, non-intensive)


OUTPATIENT

TOTAL BOX




D6b. 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 _______________

D6c. How many of the clients from the OUTPATIENT TOTAL BOX received:

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

ENTER A NUMBER FOR EACH

(IF NONE, ENTER “0”)


Methadone dispensed at this

facility for opioid use disorder _______________

Buprenorphine products dispensed or

prescribed at this facility

for opioid use disorder _______________

Naltrexone administered

at this facility for

opioid use disorder _______________

D6d. 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”)

Disulfiram dispensed

or prescribed at this facility

for alcohol use disorder _______________

Naltrexone dispensed

or prescribed at this facility

for alcohol use disorder _______________

Acamprosate dispensed

or prescribed at this facility

for alcohol use disorder _______________



Shape41

all substance use treatment settings

Including Hospital Inpatient,

Residential (non‑hospital) and/or Outpatient











D7. This question asks you to categorize the substance use treatment clients at this facility into three groups: clients in treatment for (1) use of both alcohol and substances other than alcohol; (2) use only of alcohol; or (3) use only of substances other than alcohol.

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

Use either numbers OR percentage, whichever is more convenient.

  • If numbers are used—each category total should equal the number reported in the combined total patients and clients that are recorded in QXAa, QXBa, and QXCa.

  • If percents are used—each category total should equal 100%.

Clients in treatment for use of:


NUMBER

OR

PERCENT

BOTH alcohol and substances other than alcohol




ONLY alcohol




ONLY substances other than alcohol




TOTAL:


QXAa + QXBa + QXCa


100%

D8. Approximately what percent of the substance use treatment clients enrolled at this facility on March 31, 2021, had a diagnosed co-occurring mental disorder and substance use disorder?

PERCENT OF CLIENTS

(IF NONE, ENTER “0”)

%

D9. Using the most recent 12-month period for which you have data, approximately how many substance use disorder 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 disorder treatment, even if substance use disorder was their secondary diagnosis.

NUMBER OF SUBSTANCE USE DISORDER TREATMENT ADMISSIONS IN

A 12-MONTH PERIOD






MENTAL HEALTH COUNTS

HOSPITAL INPATIENT CLIENT COUNTS



D10. On March 31, 2021, did any patients receive 24‑hour hospital inpatient treatment for mental disorders at this facility, at this location?

Yes SKIP TO D10a

No SKIP TO D11





D10a. On March 31, 2021, how many patients received 24‑hour hospital inpatient treatment for mental disorders at this facility?



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



HOSPITAL INPATIENTS

TOTAL BOX






D10b. On March 31, 2021, how many hospital inpatient beds at this facility were specifically designated for providing treatment of mental disorders?



NUMBER OF

BEDS



(If none, enter ‘0’)



















D10c. For each category below, please provide a breakdown of the Hospital Inpatients on March 31, 2021 reported in the 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 TOTAL BOX above.

  • If percents are used—each category total should equal 100%.





NUMBER

OR

PERCENT

SEX

Male





Female





CATEGORY TOTAL: (Should=TOTAL or 100%)



100%






AGE

0-17





18-64





65 and older





CATEGORY TOTAL: (Should=TOTAL or 100%)



100%






ETHNICITY

Hispanic or Latino………………………………





Not Hispanic or Latino





Unknown or not collected





CATEGORY TOTAL: (Should=TOTAL or 100%)



100%






RACE

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=TOTAL or 100%)



100%






LEGAL STATUS

Voluntary





Involuntary, non-forensic





Involuntary, forensic





CATEGORY TOTAL: (Should=B3b1 or 100%)



100%











RESIDENTIAL (NON-

HOSPITAL) CLIENT COUNTS







D11. On March 31, 2021, did any patients receive 24‑hour residential mental disorder treatment at this facility, at this location?

Yes

No





D11a. On March 31, 2021, how many patients received 24‑hour residential treatment of mental disorders at this facility?



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



RESIDENTIAL CLIENTS

TOTAL BOX






D11b. On March 31, 2021, how many residential beds at this facility were specifically designated for providing mental disorder treatment?



NUMBER OF

BEDS



(If none, enter ‘0’)





























D11c. For each category below, please provide a breakdown of the Residential Clients on March 31, 2021 reported in the 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 TOTAL BOX above.

  • If percents are used—each category total should equal 100%.





NUMBER

OR

PERCENT

SEX

Male





Female





CATEGORY TOTAL: (Should=TOTAL or 100%)



100%






AGE

0-17





18-64





65 and older





CATEGORY TOTAL: (Should=TOTAL or 100%)



100%






ETHNICITY

Hispanic or Latino………………………………





Not Hispanic or Latino





Unknown or not collected





CATEGORY TOTAL: (Should=TOTAL or 100%)



100%






RACE

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=TOTAL or 100%)



100%






LEGAL STATUS

Voluntary





Involuntary, non-forensic





Involuntary, forensic





CATEGORY TOTAL: (Should=TOTAL or 100%)



100%











OUTPATIENT CLIENT COUNTS







D12. During the month of March 2021, did any clients receive less than 24‑hour treatment of mental disorders at this facility, at this location?

Yes SKIP TO D12a

No SKIP TO D13





D12a. During the month of March 2021, how many clients received less than 24‑hour treatment of mental disorders at this facility?



        • ONLY INCLUDE those seen at this facility at least once during the month of March, AND who were still enrolled in treatment on March 31, 2021.

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



OUTPATIENT CLIENTS AND PARTIAL HOSPITALIZATION/DAY TREATMENT CLIENTS

TOTAL BOX




































D12b. For each category below, please provide a breakdown of the Clients in Less Than 24-Hour Care reported in the 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 TOTAL BOX above.

  • If percents are used—each category total should equal 100%.





NUMBER

OR

PERCENT

SEX

Male





Female





CATEGORY TOTAL: (Should=TOTAL or 100%)



100%






AGE

0-17





18-64





65 and older





CATEGORY TOTAL: (Should=TOTAL or 100%)



100%






ETHNICITY

Hispanic or Latino………………………………





Not Hispanic or Latino





Unknown or not collected





CATEGORY TOTAL: (Should=TOTAL or 100%)



100%






RACE

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=TOTAL or 100%)



100%






LEGAL STATUS

Voluntary





Involuntary, non-forensic





Involuntary, forensic





CATEGORY TOTAL: (Should=TOTAL or 100%)



100%





D13. On March 31, 2021, approximately what percent of the clients/patients enrolled at this facility had diagnosed co-occurring mental and substance use disorders?

PERCENT WITH
CO-OCCURRING DIAGNOSIS

%


(If none, enter ‘0’)

D14. In the 12-month period of April 1, 2020 through March 31, 2021, how many mental disorder 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 DISORDER IS A SECONDARY DIAGNOSIS: Count all admissions where clients/patients received mental health treatment.



NUMBER OF MENTAL Disorder TREATMENT ADMISSIONS IN 12‑MONTH PERIOD



(If none, enter ‘0’)

D15. What percent of the admissions reported in the previous question were military veterans? Please give your best estimate.



PERCENT MILITARY VETERANS

%


(If none, enter ‘0’)



RESPONDENT INFORMATION



E1. 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

Ms.

Mr.

Mrs.

Dr.

Other (Specify____)

Name: __________________________________________

Title: ____________________________________________

Phone Number: (________) __________ - __________ Ext.

Fax Number: (________) __________ - __________

Email Address: ___________________________________

Facility Email Address: _____________________________



ADDITIONAL FACILITIES INCLUDED IN CLIENT/PATIENT COUNTS







FACILITY NAME:

ADDRESS:

CITY:

STATE: ZIP:

TELEPHONE:

FACILITY EMAIL

ADDRESS:

¨ HOSPITAL INPATIENT

¨ RESIDENTIAL

¨ OUTPATIENT

¨ PARTIAL HOSPITALIZATION/DAY TREATMENT



FACILITY NAME:

ADDRESS:

CITY:

STATE: ZIP:

TELEPHONE:

FACILITY EMAIL

ADDRESS:

¨ HOSPITAL INPATIENT

¨ RESIDENTIAL

¨ OUTPATIENT

¨ PARTIAL HOSPITALIZATION/DAY TREATMENT

FACILITY NAME:

ADDRESS:

CITY:

STATE: ZIP:

TELEPHONE:

FACILITY EMAIL

ADDRESS:

¨ HOSPITAL INPATIENT

¨ RESIDENTIAL

¨ OUTPATIENT

¨ PARTIAL HOSPITALIZATION/DAY TREATMENT





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