N-SUMHSS 2021 Web N-SUMHSS 2021 Web Survey Prototype

Attachment B3: N-SUMHSS web survey prototype

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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

SUBSTANCES 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?

SELECT “YES” OR “NO” FOR EACH

Intake, assessment, or referral	Yes No
Detoxification (medical withdrawal)	Yes No
Substance use disorder treatment (services that focus on initiating and maintaining an individual’s recovery from substance use and on averting relapse)	Yes No
Treatment for co-occurring substance use plus either serious mental illness (SMI) in adults and/or serious emotional disturbance (SED) in children	Yes No
Any other substance use treatment services (such as 12 step meeting facilitation, naloxone prescriptions, etc.)	Yes No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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)?

SELECT 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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

SELECT ALL THAT APPLY

• Alcohol

• Benzodiazepines

• Cocaine

• Methamphetamines

• Opioids

• Other(s):(Specify________________)

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

SELECT “YES” OR “NO” FOR EACH

Inpatient detoxification (Medical Withdrawal) (medically managed or monitored inpatient detoxification)	Yes No
Inpatient treatment (medically managed or monitored intensive inpatient treatment))	Yes No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*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

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

SELECT “YES” OR “NO” FOR EACH

Residential detoxification (medical withdrawal) (clinically managed residential detoxification or social detoxification)	Yes No
Residential short-term treatment (clinically managed high-intensity residential treatment, typically 30 days or less)	Yes No
Residential long-term treatment (clinically managed medium- or low-intensity residential treatment)	Yes No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

SELECT “YES” OR “NO” FOR EACH

Outpatient detoxification (Ambulatory detoxification)	Yes No
Outpatient methadone/buprenorphine maintenance or naltrexone treatment	Yes No
Outpatient day treatment or partial hospitalization (20 or more hours per week)	Yes No
Intensive outpatient treatment (9 or more hours per week)	Yes No
Regular outpatient treatment (outpatient treatment, non-intensive)	Yes No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*A7. Which of the following services are offered by this facility at this location; that is, the location listed on the front cover? (SELECT 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 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

• 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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*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.

SELECT ALL THAT APPLY

• 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.)

• 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.)

• 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).

• This facility does not treat opioid use disorder

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

SELECT 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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

SELECT 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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*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.

SELECT ALL THAT APPLY

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

• This facility administers/prescribes disulfiram for alcohol use disorder

• This facility administers/prescribes naltrexone for alcohol use disorder

• This facility administers/prescribes acamprosate for alcohol use disorder

• 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

• This facility does not treat alcohol use disorder

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

SELECT 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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*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

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

A12. Does this facility provide treatment services for…?

• Marijuana

• Stimulants

• Other substance(s) (Specify:________________________________________________ )

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*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)?

• Select “yes” if either a staff counselor or an on‑call interpreter provides this service.

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

SELECT ONLY ONE

• Staff counselor who speaks a language other than English

• On-call interpreter (in person or by phone) brought in when needed

• BOTH staff counselor and on-call interpreter

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*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.

SELECT 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 languages

• Creole

• Farsi

• French

• German

• Greek

• Hebrew

• Hindi

• Hmong

• Italian

• Japanese

• Korean

• Polish

• Portuguese

• Russian

• Tagalog

• Vietnamese

• Any Other language (Specify:_________)

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*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

		LOWEST AGE SERVED	HIGHEST AGE SERVED
Male	Yes No	_______ No minimum Age	_______ No Maximum Age
Female	Yes No	_______ No minimum Age	_______ No Maximum Age

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*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 select the box for that category.

SELECT 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 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 group for any other types of clients (Specify:_____)

• No specifically tailored programs or groups are offered

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*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?

• Yes

• No

• Don’t know

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

SELECT 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: _________________________________________________ )

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*A18a. What type of hospital?

SELECT ONLY ONE

• General hospital (including VA hospital)

• Psychiatric hospital

• Other specialty hospital, for example, alcoholism, maternity, etc. (Specify:__________)

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*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.

SELECT 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)

• 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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

MENTAL DISORDERS TREATMENT FACILITIES

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

SELECT “YES” OR “NO” FOR EACH

Mental health intake	Yes No
Mental health diagnostic evaluation	Yes No
Mental health information and/or referral (also includes emergency programs that provide services in person or by telephone)	Yes No
Treatment for co-occurring disorders plus either serious mental illness (SMI) in adults and/or serious emotional disturbance (SED) in children	Yes No
Substance use treatment	Yes No
Administrative or operational services for mental health treatment facilities	Yes No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*B2. Mental health treatment is provided in which of the following service settings at this facility, at this location?

SELECT “YES” OR “NO” FOR EACH

24-hour hospital inpatient	Yes No
24-hour residential	Yes No
Partial hospitalization/day treatment	Yes No
Outpatient	Yes No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

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

SELECT ONLY ONE

• Psychiatric hospital

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

• 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

• Community Mental Health Center (CMHC)

• Certified Community Behavioral Health Clinic (CCBHC)

• Partial hospitalization/day treatment facility

• Outpatient mental health facility

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

• Other (Specify: _________________________________________________ )

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

SELECT 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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*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

SELECT 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 (Specify: _________________________________________________ )

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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*B7a. Which of the following antipsychotics are used for the treatment of SMI at this facility, at this location?

SELECT ALL THAT APPLY

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:______)

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 first-generation antipsychotics (Specify:______)

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• For definitions, go to: INSERT LINK

SELECT 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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

SELECT 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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

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

SELECT “YES” OR “NO” FOR EACH

Young children (0-5)	Yes No
Children (6-12)	Yes No
Adolescents (13-17)	Yes No
Young adults (18-25)	Yes No
Adults (26-64)	Yes No
Older adults (65 or older)	Yes No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*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 select the box for that category.

SELECT 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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*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)?

• Select “yes” if either a staff counselor or an on‑call interpreter provides this service

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

SELECT ONLY ONE

• Staff counselor who speaks a language other than English

• On-call interpreter (in person or by phone) brought in when needed

• BOTH staff counselor and on-call interpreter

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*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.

SELECT 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 languages

• Creole

• Farsi

• French

• German

• Greek

• Hebrew

• Hindi

• Hmong

• Italian

• Japanese

• Korean

• Polish

• Portuguese

• Russian

• Tagalog

• Vietnamese

• Any Other language (Specify:_________)

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

SELECT “YES” OR “NO” FOR EACH

Continuing education requirements for professional staff	Yes No
Regularly scheduled case review with a supervisor	Yes No
Regularly scheduled case review by an appointed quality review committee	Yes No
Client outcome follow-up after discharge	Yes No
Continuous quality improvement processes	Yes No
Periodic client satisfaction surveys	Yes No
Clinical provider peer review (CPPR)	Yes No
Root cause analysis (RCA)	Yes No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

SELECT ALL THAT APPLY

	Not Used at This Facility	Chemical	Physical
Seclusion
Restrain

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*B19. Which of the following types of client payments, insurance, or funding are accepted by this facility for mental health treatment services?

SELECT 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: ____________________________________)

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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.

SELECT 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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*C2. Is this facility operated by

SELECT ONLY ONE

• A private for-profit organization

• A private non-profit organization

• State government

• Local, county, or community government

• Tribal government

• Federal Government

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

*C2a. Which Federal Government agency?

SELECT ONLY ONE

• Department of Veterans Affairs

• Department of Defense

• Indian Health Service

• Other (Specify:______________________)

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

SELECT ONLY ONE

• Not permitted to smoke anywhere outside or within any building

• Permitted in designated outdoor area(s)

• Permitted anywhere outside

• Permitted in designated indoor area(s)

• Permitted anywhere inside

• Permitted anywhere without restriction

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

SELECT ONLY ONE

• Not permitted to smoke anywhere outside or within any building

• Permitted in designated outdoor area(s)

• Permitted anywhere outside

• Permitted in designated indoor area(s)

• Permitted anywhere inside

• Permitted anywhere without restriction

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Sliding fee scales are based on income and other factors

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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?

sELECT ALL THAT APPLY

• Publish the street address

• Publish the mailing address

• Do not publish either address

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

FILL IN THE FOLLOWING

Name:	­­­­­­­­­­­­­­­ ________________________
Address:	________________________
Phone Number:	________________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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?

SELECT ONLY ONE

• Only this facility

• This facility plus others

• Another facility will report this facility’s client counts

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

This Facility	1
Additional Facilities	_______
Total	_______

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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?

SELECT ONLY ONE

• 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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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)

Impatient detoxification (medical withdrawal) (medically managed or monitored inpatient detoxification)	_________________
Impatient treatment (medically managed or monitored intensive inpatient treatment)	_________________
HOSPITAL INPATIENT TOTAL BOX	_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

D4b. How many of the patients from the HOSPITAL INPATIENT TOTAL BOX were under the age of 18?

ENTER A NUMBER FOR EACH (IF NONE ENTER 0)

Number under age 18

_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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.

Methadone dispense 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	_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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	_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

ENTER A NUMBER FOR EACH (IF NONE ENTER 0)

Number of Beds

_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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 high-intensity residential treatment, typically 30 days or less)	_________________
Residential Total Box	_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

D5b. How many of the clients from the RESIDENTIAL TOTAL BOX were under the age of 18?

ENTER A NUMBER FOR EACH (IF NONE ENTER 0)

Number under age 18

_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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.

Methadone dispense 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	_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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	_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

ENTER A NUMBER FOR EACH (IF NONE ENTER 0)

Number of beds

_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

OUTPATIENT CLIENT COUNTS

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

• Yes

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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?

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.

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	_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

D6b. How many of the clients from the OUTPATIENT TOTAL BOX were under the age of 18?

ENTER A NUMBER FOR EACH (IF NONE ENTER 0)

Number under age 18

_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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 dispense 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	_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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	_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

ALL SUBSTANCE USE TREATMENT SETTING

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	PERCENT
BOTH alcohol and substances other than alcohol	____________	____________
ONLY alcohol	____________	____________
ONLY substances other than alcohol	____________	____________
Total	____________	____________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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”)

_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

• No

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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”)

_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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%

SEX

	NUMBER	PERCENT
Male	_______	_______
Female	_______	_______
Total	_______	_______

AGE

	NUMBER	PERCENT
0-17	_______	_______
18-64	_______	_______
65 and older	_______	_______
Total	_______	_______

ETHNICITY

	NUMBER	PERCENT
Hispanic or Latino	_______	_______
Not Hispanic or Latino	_______	_______
Unknown or not collected	_______	_______
Total	_______	_______

RACE

	NUMBER	PERCENT
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	_______	_______
Total	_______	_______

LEGAL STATUS

	NUMBER	PERCENT
Voluntary	_______	_______
Involuntary, non-forensic	_______	_______
Involuntary, forensic	_______	_______
Total	_______	_______

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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”)

_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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%.

SEX

	NUMBER	PERCENT
Male	_______	_______
Female	_______	_______
Total	_______	_______

AGE

	NUMBER	PERCENT
0-17	_______	_______
18-64	_______	_______
65 and older	_______	_______
Total	_______	_______

ETHNICITY

	NUMBER	PERCENT
Hispanic or Latino	_______	_______
Not Hispanic or Latino	_______	_______
Unknown or not collected	_______	_______
Total	_______	_______

RACE

	NUMBER	PERCENT
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	_______	_______
Total	_______	_______

LEGAL STATUS

	NUMBER	PERCENT
Voluntary	_______	_______
Involuntary, non-forensic	_______	_______
Involuntary, forensic	_______	_______
Total	_______	_______

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

OUTPATIENT CLIENT COUNTS

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

_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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%.

SEX

	NUMBER	PERCENT
Male	_______	_______
Female	_______	_______
Total	_______	_______

AGE

	NUMBER	PERCENT
0-17	_______	_______
18-64	_______	_______
65 and older	_______	_______
Total	_______	_______

ETHNICITY

	NUMBER	PERCENT
Hispanic or Latino	_______	_______
Not Hispanic or Latino	_______	_______
Unknown or not collected	_______	_______
Total	_______	_______

RACE

	NUMBER	PERCENT
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	_______	_______
Total	_______	_______

LEGAL STATUS

	NUMBER	PERCENT
Voluntary	_______	_______
Involuntary, non-forensic	_______	_______
Involuntary, forensic	_______	_______
Total	_______	_______

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

PERCENT MILITARY VETERANS

_________________

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* 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 the National Directory of Mental Health Treatment Facilities, and other publicly-available listings, unless you designate otherwise in question C8 of this questionnaire.

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

Select One	Ms. Mr. Mrs. Dr. Other (Specify:_______)
Name:	________________________________
Title:	________________________________
Phone Number:	________________________________
Fax Number:	________________________________
Email Address:	________________________________
Facility Email Address:	________________________________

ADDITIONAL FACILITIES INCLUDED IN CLIENT/PATIENT COUNTS

Select One	Hospital Inpatient Residential Outpatient Partial Hospitalization/Day Treatment
Facility Name:	________________________________
Address:	________________________________
City:	________________________________
State:	________________________________
Zip:	________________________________
Telephone:	________________________________
Facility Email:	________________________________
Address:	________________________________

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Rodriguez, Daniel (SAMHSA) (CTR)
File Modified	0000-00-00
File Created	2021-01-13