Download:
pdf |
pdfOMB: 0930-0386
Expiration Date: XX/XX/XXXX
NATIONAL SUBSTANCE USE AND MENTAL HEALTH SERVICES SURVEY
(N-SUMHSS)
1. What type of treatment does this facility at this location, provide?
o Primarily Substance use treatment services
o Primarily Mental health services
o Mix of mental health and substance use treatment services
o No treatment for either substance use or mental health is provided at this
location
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
Pledge to Respondents: The information you provide will be protected to the fullest extent allowable under the Public Health
Service Act (42 USC 290aa(p)). This law permits the public release of identifiable information about an establishment only with
the consent of that establishment and limits the use of the information to the purposes for which it was supplied. With the explicit
consent of treatment facilities, information provided in response to survey questions marked with an asterisk may be published on
FindTreatment.gov, the National Directory of Drug and Alcohol Use Treatment Facilities, the National Directory of Mental Health
Treatment Facilities, and other publicly available listings. Responses to non-asterisked questions will be published with no direct
link to individual treatment facilities.
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0386. Public
reporting burden for this collection of information is estimated to average XX minutes per facility, per year, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 15E57-A,
Rockville, Maryland 20857.
1a. Do you also provide substance use treatment services?
Select “Yes” if this facility offers substance use treatment as a stand-alone service.
Select “No” if it only offers substance use treatment as part of mental health treatment services
for individual patients who need it.
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
2
2. Is this facility a jail, prison, or detention center that provides treatment exclusively for
incarcerated persons or juvenile detainees?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
3
MODULE A: SUBSTANCES USE TREATMENT FACILITIES
A1. Which of the following substance use treatment services are offered by this facility at this
location?
SELECT “YES” OR “NO” FOR EACH
Intake, assessment, or referral
o Yes
o No
Detoxification (medical withdrawal)
o Yes
o No
Substance use disorder treatment
(services that focus on initiating and maintaining
an individual’s recovery from substance use and
on averting relapse)
o Yes
o No
Treatment for co-occurring substance use plus
either serious mental illness (SMI) in adults
and/or serious emotional disturbance (SED) in
children
o Yes
o No
Any other substance use treatment services
(such as 12 step meeting facilitation, naloxone
prescriptions, etc.)
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
4
A1a. To which of the following clients does this facility, at this location, offer mental health
treatment services (interventions such as therapy or psychotropic medication that treat a
person’s mental health problem or condition, reduce symptoms, and improve behavioral
functioning and outcomes)?
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
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
5
*A2. Does this facility detoxify (medical withdrawal) clients from:
SELECT ALL THAT APPLY
Alcohol
Benzodiazepines
Cocaine
Methamphetamines
Opioids
Other(s):(Specify________________)
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
6
*A2a. Does this facility routinely use medication during detoxification (medical withdrawal)?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
7
A3. Is this facility a solo practice, that is, an office with only one independent practitioner or
counselor?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
8
*A4. Does this facility offer HOSPITAL INPATIENT substance use treatment services at this
location?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
9
*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)
Inpatient treatment (medically
managed or monitored intensive
inpatient treatment))
o Yes
o No
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
10
*A5. Does this facility offer RESIDENTIAL (non-hospital) substance use treatment services at this
location?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
11
*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)
Residential short-term treatment (clinically
managed high-intensity residential treatment,
typically 30 days or less)
Residential long-term treatment (clinically
managed medium- or low-intensity residential
treatment)
o Yes
o No
o Yes
o No
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
12
*A6. Does this facility offer OUTPATIENT substance use treatment services at this location?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
13
*A6a. Which of the following OUTPATIENT services are offered at this facility?
SELECT “YES” OR “NO” FOR EACH
Outpatient detoxification (Ambulatory
detoxification)
o Yes
o No
Outpatient methadone/buprenorphine
maintenance or naltrexone treatment
o Yes
o No
Outpatient day treatment or partial
hospitalization (20 or more hours per week)
o Yes
o No
Intensive outpatient treatment (9 or more hours
per week)
o Yes
o No
Regular outpatient treatment (outpatient
treatment, non-intensive)
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
14
*A7a. Which of the following assessment and pre-treatment services are offered by this facility at
this location? (SELECT ALL THAT APPLY)
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
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
15
*A7b. Which of the following testing services (include tests performed at this location, even if
specimen is sent to an outside source for chemical analysis are offered by this facility at this
location? (SELECT ALL THAT APPLY)
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
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
16
*A7c. Which of the following medical services are offered by this facility at this location?
Hepatitis A (HAV) vaccination
Hepatitis B (HBV) vaccination
None of the medical services above are offered at this facility
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
17
*A7d. Which of the following transitional services are offered by this facility at this location?
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
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
18
*A7e. Which of the following recovery support services are offered by this facility at this location?
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
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
19
*A7f. Which of the following education and counseling services are offered by this facility at this
location?
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
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
20
*A7g. Which of the following ancillary services are offered by this facility at this location?
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
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
21
*A7h. Which of the following other services are offered by this facility at this location?
Treatment for gambling disorder
Treatment for other addiction disorder (non-substance use disorder)
None of the other services above are offered at this facility
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
22
*A7i. Which of the following pharmacotherapies services are offered by this facility at this location?
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: for example, 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 [TEXT BOX]
None of the pharmacotherapy services above are offered at this facility
23
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
24
*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 FDAapproved 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
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
25
*A8a. For those clients using MAT for opioid use disorder, 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
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
26
*A8b. Does this facility serve only opioid use disorder clients?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
27
*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 (for example, 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
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
28
*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?
• NOTE: 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
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
29
*A9a. For those clients using MAT for alcohol use disorder, 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
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
30
*A9b. Does this facility serve only alcohol use disorder clients?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
31
*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
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
OPIOID USE DISORDER
OTHER SUBSTANCES
OPIOID USE DISORDER
OTHER SUBSTANCES
OPIOID USE DISORDER
OTHER SUBSTANCES
OPIOID USE DISORDER
OTHER SUBSTANCES
OPIOID USE DISORDER
OTHER SUBSTANCES
OPIOID USE DISORDER
OTHER SUBSTANCES
OPIOID USE DISORDER
OTHER SUBSTANCES
OPIOID USE DISORDER
OTHER SUBSTANCES
OPIOID USE DISORDER
OTHER SUBSTANCES
OPIOID USE DISORDER
OTHER SUBSTANCES
OPIOID USE DISORDER
OTHER SUBSTANCES
OPIOID USE DISORDER
OTHER SUBSTANCES
OPIOID USE DISORDER
OTHER SUBSTANCES
OPIOID USE DISORDER
OTHER SUBSTANCES
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
32
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
33
*A11. Does this facility, at this location, offer a specially designed program or group intended
exclusively for DUI/DWI or other drunk driver offenders?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
34
*A11a. Does this facility serve only DUI/DWI clients?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
35
A12. Does this facility provide treatment services for…?
o Marijuana
o Stimulants
o Other substance(s) (Specify:________________________________________________ )
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
36
*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.
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
37
*A14. Does this facility provide substance use treatment services in a language other than
English at this location?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
38
A14a. At this facility, who provides substance use treatment services in a language other than
English?
SELECT ONLY ONE
o Staff counselor who speaks a language other than English
o On-call interpreter (in person or by phone) brought in when needed
o BOTH staff counselor and on-call interpreter
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
39
*A14a1. Do staff counselors provide substance use treatment in Spanish at this facility?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
40
A14a2. Do staff counselors at this facility provide substance use treatment in any other
languages?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
41
*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:_________)
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
42
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
43
*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?
Male
o Yes
o No
Female
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
44
*A15F. What is the minimum or maximum age of females served by this facility?
▪
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
o Yes, there is a minimum age
_______
o No minimum age
HIGHEST AGE SERVED
o Yes, there is a maximum age
_______
o No maximum age
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
45
*A15M. What is the minimum or maximum age of males served by this facility?
▪
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
o Yes, there is a minimum age
_______
o No minimum age
HIGHEST AGE SERVED
o Yes, there is a maximum age
_______
o No maximum age
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
46
*A15a. 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 co-occurring pain and substance use disorders
Clients with HIV or AIDS
Clients who have experienced sexual abuse
Clients who have experienced intimate partner violence, domestic violence
Clients who have experienced trauma
Specifically tailored programs or groups for any other types of clients (Specify:_____)
No specifically tailored programs or groups are offered
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
47
*A16. Does this facility receive any funding or grants from the Federal Government or state,
county or local governments, to support its substance use treatment programs?
Do not include Medicare, Medicaid, or federal military insurance. These forms of client payments are
included in the following question (A17).
o Yes
o No
o Don’t know
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
48
*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: _________________________________________________ )
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
49
*A18. Is this facility a hospital or located in or operated by a hospital?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
50
*A18a. What type of hospital?
SELECT ONLY ONE
o General hospital (including VA hospital)
o Psychiatric hospital
o Other specialty hospital (for example, alcoholism, maternity, etc.) (Specify:__________)
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
51
A19. Does this facility operate as a skilled nursing facility (SNF) that provides services for
substance use disorders?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
52
*A20. Does this facility operate transitional housing, a halfway house, or a sober home for
substance use clients at this location?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
53
*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)
Healthcare Facilities Accreditation Program (HFAP)
SAMHSA certification for opioid treatment program (OTP)
Drug Enforcement Agency (DEA)
Other national organization or federal, state, or local agency (Specify:
_________________________________________________ )
This facility is not licensed, certified, or accredited to provide substance use services by
any of these organizations
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
54
MENTAL DISORDERS TREATMENT FACILITIES
B1. Does this treatment facility, at this location, offer:
SELECT “YES” OR “NO” FOR EACH
Mental health intake
o Yes
o No
Mental health diagnostic evaluation
o Yes
o No
Mental health information and/or referral (also
includes emergency programs that provide
services in person or by telephone)
o Yes
o No
Mental health treatment (interventions such as
therapy or psychotropic medication that treat a
person’s mental disorder or condition, reduce
symptoms, and improve behavioral functioning
and outcomes)
o Yes
o No
Treatment for co-occurring disorders plus either
serious mental illness (SMI) in adults and/or
serious emotional disturbance (SED) in children
o Yes
o No
Substance use treatment
o Yes
o No
Administrative or operational services for mental
health treatment facilities
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
55
*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
o Yes
o No
24-hour residential
o Yes
o No
Partial hospitalization/day treatment
Outpatient
o Yes
o No
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
56
*B3. Which ONE category BEST describes this facility, at this location?
▪
For definitions of facility types, go to: https://info.nsumhss.samhsa.gov/definitions.htm
SELECT ONLY ONE
o Psychiatric hospital
o Separate inpatient psychiatric unit of a general hospital (consider this psychiatric unit as the relevant
“facility” for the purpose of this survey)
o State hospital
o Residential treatment center for children
o Residential treatment center for adults
o Other type of residential treatment facility
o Veterans Affairs Medical Center (VAMC) or other VA health care facility
o Community Mental Health Center (CMHC)
o Certified Community Behavioral Health Clinic (CCBHC)
o Partial hospitalization/day treatment facility
o Outpatient mental health facility
o Multi-setting mental health facility (non-hospital residential plus either outpatient and/or partial
hospitalization/day treatment)
o Other (Specify: _________________________________________________ )
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
57
B4. Is this facility either a solo or a small group practice?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
58
*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.
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
59
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
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
60
*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
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
61
*B7. Does this facility offer the use of antipsychotics for the treatment of serious mental
illness (SMI)?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
62
*B7a. Which of the following antipsychotics are used for the treatment of SMI at this facility, at
this location?
SELECT ALL THAT APPLY
FIRSTGENERATION
ANTIPSYCHOTIC
Chlorpromazine
Droperidol
Fluphenazine
Haloperidol
Loxapine
Perphenazine
Pimozide
Prochlorperazine
Thiothixene
Not Used At This Facility
Oral
Injectable
Rectal
Don’t Know
Not Used At This Facility
Injectable
Don’t Know
Not Used At This Facility
Oral
Injectable
Don’t Know
Not Used At This Facility
Oral
Injectable
Don’t Know
Not Used At This Facility
Oral
Injectable
Inhalation
Don’t Know
Not Used At This Facility
Oral
Injectable
Don’t Know
Not Used At This Facility
Oral
Topical
Don’t Know
Not Used At This Facility
Oral
Injectable
Rectal
Don’t Know
Not Used At This Facility
Oral
Injectable
63
Thioridazine
Trifluoperazine
Other firstgeneration
antipsychotic #1
(Specify:______)
Other firstgeneration
antipsychotic #2
(Specify:______)
Other firstgeneration
antipsychotic #3
(Specify:______)
Don’t Know
Not Used At This Facility
Oral
Don’t Know
Not Used At This Facility
Oral
Injectable
Don’t Know
Not Used At This Facility
Oral
Injectable
Long-acting Injectable
Rectal
Topical
Inhalation
Don’t Know
Not Used At This Facility
Oral
Injectable
Long-acting Injectable
Rectal
Topical
Inhalation
Don’t Know
Not Used At This Facility
Oral
Injectable
Long-acting Injectable
Rectal
Topical
Inhalation
Don’t Know
SECOND-GENERATION
ANTIPSYCHOTIC
Aripiprazole
Asenapine
Not Used At This Facility
Oral/Sublingual
Injectable
Long-acting Injectable
Don’t Know
Not Used At This Facility
Oral/Sublingual
Topical/Transdermal
Don’t Know
64
Brexpiprazole
Cariprazine
Clozapine
IIoperidone
Lurasidone
Olanzapine
Olanzapine/
Fluoxetine combination
Paliperidone
Quetiapine
Risperidone
Ziprasidone
Other second-generation
antipsychotic #1
(Specify:______)
Not Used At This Facility
Oral/Sublingual
Don’t Know
Not Used At This Facility
Oral/Sublingual
Don’t Know
Not Used At This Facility
Oral/Sublingual
Don’t Know
Not Used At This Facility
Oral/Sublingual
Don’t Know
Not Used At This Facility
Oral/Sublingual
Don’t Know
Not Used At This Facility
Oral/Sublingual
Injectable
Long-acting Injectable
Don’t Know
Not Used At This Facility
Oral/Sublingual
Don’t Know
Not Used At This Facility
Oral/Sublingual
Injectable
Long-acting Injectable
Don’t Know
Not Used At This Facility
Oral/Sublingual
Don’t Know
Not Used At This Facility
Oral/Sublingual
Injectable
Long-acting Injectable
Don’t Know
Not Used At This Facility
Oral/Sublingual
Injectable
Don’t Know
Not Used At This Facility
Oral/Sublingual
Injectable
Long-acting Injectable
65
Other second-generation
antipsychotic #2
(Specify:______)
Other second-generation
antipsychotic #3
(Specify:______)
Rectal
Topical/Transdermal
Don’t Know
Not Used At This Facility
Oral/Sublingual
Injectable
Long-acting Injectable
Rectal
Topical/Transdermal
Don’t Know
Not Used At This Facility
Oral/Sublingual
Injectable
Long-acting Injectable
Rectal
Topical/Transdermal
Don’t Know
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
66
*B8. Which of these services and practices are offered at this facility, at this location?
• For definitions, go to: https://info.nsumhss.samhsa.gov/definitions.htm
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
67
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
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
68
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
69
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, acamprosate)
Medication-assisted treatment for opioid use disorder (for example, buprenorphine, methadone,
naltrexone)
Individual counseling
Group counseling
12-Step groups
Case management
Other (Specify: ___________________)
None of these services are offered at this facility
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
70
*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)
o Yes
o No
Children (6-12)
o Yes
o No
Adolescents (13-17)
o Yes
o No
Young adults (18-25)
o Yes
o No
Adults (26-64)
o Yes
o No
Older adults (65 or older)
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
71
Facilities and the National Directory of Mental Health Treatment Facilities, and other publicly-available
listings, unless you designate otherwise in question C8 of this questionnaire.
72
*B11. Does this facility currently 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
Clients 18 and older with serious mental illness (SMI)
Older adults
Clients with Alzheimer’s disease or dementia
Clients with co-occurring mental and substance use disorders
Clients with eating disorders
Clients experiencing first-episode psychosis
Clients who have experienced intimate partner violence, domestic violence
Clients with a diagnosis of post-traumatic stress disorder (PTSD)
Clients who have experienced trauma (excluding persons with a PTSD diagnosis)
Clients 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)
Clients with HIV or AIDS
Other special program or group (Specify: ____________________________________________)
No dedicated or exclusively designed programs or groups are offered at this facility
73
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
74
*B12. Does this facility offer a crisis intervention team that handles acute mental health issues at
this facility and/or off-site?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
75
*B13. Does this facility offer services for psychiatric emergencies onsite?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
76
*B14. Does this facility offer mobile/off-site psychiatric crisis services?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
77
*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
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
78
*B16. Does this facility provide mental health treatment services in a language other than English
at this location?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
79
B16a. At this facility, who provides mental treatment services in a language other than
English?
SELECT ONLY ONE
o Staff counselor who speaks a language other than English
o On-call interpreter (in person or by phone) brought in when needed
o BOTH staff counselor and on-call interpreter
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
80
*B16a1. Do staff counselors provide mental health treatment in Spanish at this facility?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
81
B16a2. Do staff counselors at this facility provide mental health treatment in any other languages?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
82
*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:_________)
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
83
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
84
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
o Yes
o No
Regularly scheduled case review with a
supervisor
o Yes
o No
Regularly scheduled case review by an
appointed quality review committee
o Yes
o No
Client outcome follow-up after discharge
o Yes
o No
Continuous quality improvement processes
o Yes
o No
Periodic client satisfaction surveys
o Yes
o No
Clinical provider peer review (CPPR)
o Yes
o No
Root cause analysis (RCA)
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
85
B18. In the 12-month period beginning April X, 202X, and ending March 31, 202X, have staff at this
facility used:
SELECT ALL THAT APPLY
Seclusion
Not Used at
This Facility
Chemical
Physical
Restraint
Not Used at
This Facility
Chemical
Physical
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
86
B18a. Does this facility have any policies in place to minimize the use of seclusion or restraint?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
87
*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 Services Block Grants (CSBG)
Community Mental Health Services Block Grants (MHBG)
Other 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: ____________________________________)
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
88
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
89
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
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
90
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
91
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:
https://info.nsumhss.samhsa.gov/definitions.htm#fqhc
o Yes
o No
o Don’t know
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
92
*C2. Is this facility operated by…
SELECT ONLY ONE
o A private for-profit organization
o A private non-profit organization
o State government
o Local, county, or community government
o Tribal government
o Federal Government
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
93
*C2a. Which Federal Government agency?
SELECT ONLY ONE
o Department of Veterans Affairs
o Department of Defense
o Indian Health Service
o Other (Specify:______________________)
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
94
C3. Is this facility affiliated with a religious (or faith-based) organization?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
95
*C4. Which of the following statements BEST describes this facility’s smoking policy for clients?
SELECT ONLY ONE
o Not permitted to smoke anywhere outside or within any building
o Permitted in designated outdoor area(s)
o Permitted anywhere outside
o Permitted in designated indoor area(s)
o Permitted anywhere inside
o Permitted anywhere without restriction
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
96
*C5. Which of the following statements BEST describes this facility’s vaping policy for clients?
SELECT ONLY ONE
o Not permitted to smoke anywhere outside or within any building
o Permitted in designated outdoor area(s)
o Permitted anywhere outside
o Permitted in designated indoor area(s)
o Permitted anywhere inside
o Permitted anywhere without restriction
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
97
*C6. Does this facility use a sliding fee scale?
•
Sliding fee scales are based on income and other factors.
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
98
C6a. Do you want the availability of a sliding fee scale published on FindTreatment.gov, the National
Directory of Mental Health Treatment Facilities, and the National Directory of Drug and Alcohol Use
Treatment Facilities?
•
FindTreatment.gov, the National Directory of Mental Health Treatment Facilities, and the National
Directory of Drug and Alcohol Use Treatment Facilities will explain that potential clients should
call the facility for information on eligibility.
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
99
*C7. Does this facility offer treatment at no charge or minimal payment (for example, $1) to clients
who cannot afford to pay?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
100
C7a. Do you want the availability of treatment at no charge or minimal payment (for example, $1)
for eligible clients published on FindTreatment.gov, the National Directory of Mental Health
Treatment Facilities, and the National Directory of Drug and Alcohol Use Treatment Facilities?
•
FindTreatment.gov, the National Directory of Mental Health Treatment Facilities, and the National
Directory of Drug and Alcohol Use Treatment Facilities will explain that potential clients should
call the facility for information on eligibility.
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
101
C8. If eligible, does this facility want to be listed on FindTreatment.gov (https://findtreatment.gov),
the National Directory of Mental Health Treatment Facilities, and the National Directory of Drug and
Alcohol Use Treatment Facilities (https://www.samhsa.gov/data)
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
102
C8a. Does this facility want the street address and/or mailing address to be listed on
FindTreatment.gov, the National Directory of Mental Health Treatment Facilities, and the National
Directory of Drug and Alcohol Use Treatment Facilities?
SELECT ALL THAT APPLY
Publish the street address
Publish the mailing address
Do not publish either address
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
103
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.
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
104
C9. Is this facility part of an organization with multiple facilities or sites that provide substance use or
mental disorder treatment?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
105
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
Facility Name Line 1:
________________________
Facility Name Line 2
________________________
Street Address:
________________________
Street Address 2
________________________
City
________________________
State
[DROPDOWN OF STATES]
Zip
________________________
Phone Number:
________________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
106
MODULE D: CLIENT COUNTS SECTION
D1. The next set of questions ask about the number of clients in treatment for specific dates.
Questions will ask for one day, one month, or 12-month counts. You may find it helpful to view the
questions in advance before completing this section.
View Client Counts Worksheet
Although reporting client counts for each individual facility is preferred, we realize that may not be
possible. You may report counts for a group of facilities by selecting those facilities on upcoming
screens, and only need to report one set of counts for that group.
For EACH facility listed below please indicate how you will report the number of clients receiving
treatment for THAT facility.
•
•
•
To report client counts for that facility alone, please select “Only this facility”
To report client counts for that facility and other facilities in the same network, please select
“This facility plus others”
If client counts for that facility will be reported by another facility in the same network,
please select “Another facility will report this facility’s counts”
SELECT ONLY ONE
o Only this facility
o This facility plus others
o Another facility will report this facility’s client counts
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
107
D4. On March XX, 202X, did any patients receive INPATIENT substance use disorder treatment services
at this facility?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use
Treatment Facilities and the National Directory of Mental Health Treatment Facilities, and other
publicly-available listings, unless you designate otherwise in question C8 of this
questionnaire.
108
D4a. On March XX, 202X, 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
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
109
D4b. How many of the total HOSPITAL INPATIENTS were under the age of 18?
ENTER A NUMBER FOR EACH (IF NONE, ENTER “0”)
Number under age 18
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
110
D4c. How many of the total HOSPITAL INPATIENTS received:
• Include patients who received these drugs for detoxification (medical withdrawal), maintenance,
or relapse prevention treatment for opioid use disorder.
ENTER A NUMBER FOR EACH (IF NONE, ENTER “0”)
Methadone dispensed at this facility for opioid
use disorder
_________________
Buprenorphine products dispensed or
prescribed at this facility for opioid use disorder
_________________
Naltrexone administered at this facility for opioid
use disorder
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
111
D4d. How many of the total HOSPITAL INPATIENTS 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
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
112
D4e. On March XX, 202X, 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
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
113
D5. On March XX, 202X, did any clients receive RESIDENTIAL (non-hospital) substance use
disorder treatment services at this facility?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
114
D5a. On March XX, 202X, how many clients received the following RESIDENTIAL substance use
disorder treatment services at this facility?
• COUNT a client in one service only, even if the client received multiple services.
• DO NOT count family members, friends, or other non-treatment clients.
ENTER A NUMBER FOR EACH (IF NONE, ENTER “0”)
Residential detoxification (medical withdrawal)
(clinically managed residential detoxification or
social detoxification)
Residential short-term treatment (clinically
managed high-intensity residential treatment,
typically 30 days or less)
Residential long-term treatment (clinically
_________________
_________________
managed medium- or low-intensity residential
treatment, typically more than 30 days)
_________________
Residential Total
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
115
D5b. How many of the total RESIDENTIAL clients were under the age of 18?
ENTER A NUMBER FOR EACH (IF NONE, ENTER “0”)
Number under age 18
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
116
D5c. How many of the total RESIDENTIAL clients received:
• Include clients who received these drugs for detoxification, maintenance, or relapse prevention for opioid use
disorder.
ENTER A NUMBER FOR EACH (IF NONE, ENTER “0”)
Methadone dispensed at this facility for opioid
use disorder
_________________
Buprenorphine products dispensed or
prescribed at this facility for opioid use disorder
_________________
Naltrexone administered at this facility for opioid
use disorder
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
117
D5d. How many of the total RESIDENTIAL clients 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
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
118
D5e. On March XX, 202X, how many residential beds were specifically designated for substance
use disorder treatment?
ENTER A NUMBER FOR EACH (IF NONE, ENTER “0”)
Number of beds
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
119
OUTPATIENT CLIENT COUNTS
D6. During the month of March 202X, did any clients receive OUTPATIENT substance use disorder
treatment services at this facility?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
120
D6a. As of March XX, 202X, 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 XX, 202X.
• 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
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
121
D6b. How many of the total OUTPATIENT clients were under the age of 18?
ENTER A NUMBER FOR EACH (IF NONE, ENTER “0”)
Number under age 18
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
122
D6c. How many of the total OUTPATIENT clients received:
•
Include clients who received these drugs for detoxification (medical withdrawal), maintenance, or
relapse prevention for opioid use disorder
ENTER A NUMBER FOR EACH (IF NONE, ENTER “0”)
Methadone dispensed at this facility for opioid
use disorder
_________________
Buprenorphine products dispensed or
prescribed at this facility for opioid use disorder
_________________
Naltrexone administered at this facility for opioid
use disorder
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
123
D6d. How many total OUTPATIENT clients 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
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
124
D7. In the next section, you will be asked 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. You may report these
breakdowns using either numbers OR percents, whichever is more convenient. How would you like to
report these counts?
If numbers are used—the total should equal the number reported in the combined total patients and
clients that are recorded in D4a, D5a, and D6a.
If percents are used—the total should equal 100%.
o Numbers
o Percents
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
125
D7a. 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 XX, 202X, who were in each of these three groups.
Use either numbers OR percentage, whichever is more convenient.
• If numbers are used—the total should equal the number reported in the combined total patients
and clients that are recorded in D4a, D5a, and D6a.
• If percents are used—the 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
____________
____________
(D4a + D5a + D6a)
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
126
D8. Approximately what percent of the substance use treatment clients enrolled at this facility
on March XX, 202X, had a diagnosed co-occurring mental disorder and substance use disorder?
Percent of Clients (If none, enter ”0”)
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
127
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
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
128
MENTAL HEALTH COUNTS
HOSPITAL INPATIENT CLIENT COUNTS
The next set of questions ask about the number of mental health clients in treatment for specific dates.
Questions will ask for one day, one month, or 12-month counts. You may find it helpful to view the
questions in advance before completing this section.
View Client Counts Worksheet
D10. On March XX, 202X, did any patients receive 24-hour hospital inpatient treatment for mental
disorders at this facility, at this location?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
129
D10a. On March XX, 202X, 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
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
130
D10b. On March XX, 202X, how many hospital inpatient beds at this facility were specifically
designated for providing treatment of mental disorders?
Number of Beds (If none, enter “0”)
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
131
D10c. In the next section, you will be asked to provide a breakdown of the total Hospital Inpatients you
reported previously by Sex, Age, Ethnicity, Race, and Legal Status. You may report these breakdowns
using either numbers OR percents, whichever is more convenient. How would you like to report these
counts?
If numbers are used—each category total should equal the number reported for total Hospital Inpatients.
If percents are used—each category total should equal 100%.
o Numbers
o Percents
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
132
D10c1. For each category below, please provide a breakdown of the total Hospital Inpatients you
reported previously. If numbers are used—each category total should equal the number reported for
total Hospital Inpatients.
• If percents are used—each category total should equal 100%
SEX
NUMBER
PERCENT
Male
_______
_______
Female
_______
_______
Total
_______
_______
D10c2. AGE
NUMBER
PERCENT
0-17
_______
_______
18-64
_______
_______
65 and older
_______
_______
Total
_______
_______
D10c3. ETHNICITY
NUMBER
PERCENT
Hispanic or Latino
_______
_______
Not Hispanic or Latino
_______
_______
Unknown or not collected
_______
_______
Total
_______
_______
D10c4. 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
_______
_______
D10c5. LEGAL STATUS
NUMBER
PERCENT
Voluntary
_______
_______
Involuntary, non-forensic
_______
_______
Involuntary, forensic
_______
_______
133
Total
_______
_______
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
134
RESIDENTIAL (NON-HOSPITAL) CLIENT COUNTS
D11. On March XX, 202X, did any patients receive 24-hour residential mental disorder treatment at
this facility, at this location?
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
135
D11a. On March XX, 202X, 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
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
136
D11b. On March XX, 202X, how many residential beds at this facility were specifically
designated for providing mental disorder treatment?
Number of Beds (If none, enter “0”)
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
137
D11c. In the next section, you will be asked to provide a breakdown of the total Residential Clients you
reported previously by Sex, Age, Ethnicity, Race, and Legal Status. You may report these breakdowns
using either numbers OR percents, whichever is more convenient. How would you like to report these
counts?
If numbers are used—each category total should equal the number reported for total Residential Clients.
If percents are used—each category total should equal 100%.
o Numbers
o Percents
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
138
D11c1. For each category below, please provide a breakdown of the Residential Clients you
reported previously.
• If numbers are used—each category total should equal the number reported for total
Residential Clients.
• If percents are used—each category total should equal 100%.
SEX
NUMBER
PERCENT
Male
_______
_______
Female
_______
_______
Total
_______
_______
D11c2. AGE
NUMBER
PERCENT
0-17
_______
_______
18-64
_______
_______
65 and older
_______
_______
Total
_______
_______
D11c3. ETHNICITY
NUMBER
PERCENT
Hispanic or Latino
_______
_______
Not Hispanic or Latino
_______
_______
Unknown or not collected
_______
_______
Total
_______
_______
D11c4. 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
_______
_______
D11c5. LEGAL STATUS
NUMBER
PERCENT
Voluntary
_______
_______
Involuntary, non-forensic
_______
_______
Involuntary, forensic
_______
_______
139
Total
_______
_______
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove
a Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
140
OUTPATIENT CLIENT COUNTS
D12. During the month of March 202X, did any clients receive less than 24-hour treatment of mental
disorders at this facility, at this location?
[ROWS]
[BLANK; NO TEXT]
o Yes
o No
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
141
D12a. During the month of March 202X, 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 XX, 202X.
DO NOT count family members, friends, or other non-treatment persons.
OUTPATIENT CLIENTS AND PARTIAL
HOSPITALIZATION/DAY TREATMENT CLIENTS
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
142
D12b. In the next section, you will be asked to provide a breakdown of the total Clients in Less Than 24Hour Care you reported previously by Sex, Age, Ethnicity, Race, and Legal Status. You may report these
breakdowns using either numbers OR percents, whichever is more convenient. How would you like to
report these counts?
If numbers are used—each category total should equal the number reported for total Clients in Less Than
24-Hour Care.
If percents are used—each category total should equal 100%.
o Numbers
o Percents
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
143
D12b1. For each category below, please provide a breakdown of the total Clients in Less Than 24Hour Care you reported previously.
• If numbers are used—each category total should equal the number reported for total Clients in
Less Than 24-Hour Care.
• If percents are used—each category total should equal 100%.
SEX
NUMBER
PERCENT
Male
_______
_______
Female
_______
_______
Total
_______
_______
D12b2. AGE
NUMBER
PERCENT
0-17
_______
_______
18-64
_______
_______
65 and older
_______
_______
Total
_______
_______
D12b3. ETHNICITY
NUMBER
PERCENT
Hispanic or Latino
_______
_______
Not Hispanic or Latino
_______
_______
Unknown or not collected
_______
_______
Total
_______
_______
D12b4. 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
_______
_______
D12b5. LEGAL STATUS
NUMBER
PERCENT
Voluntary
_______
_______
Involuntary, non-forensic
_______
_______
Involuntary, forensic
_______
_______
144
Total
_______
_______
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove
a Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
145
D13. On March XX, 202X, 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
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
146
D14. In the 12-month period of April X, 202X through March XX, 202X, 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
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
147
D15. What percent of the admissions reported in the previous question were military veterans?
Please give your best estimate.
PERCENT MILITARY VETERANS
_________________
(Show progress bar by section.) (Buttons: Back, Next, Save & Exit, Review My Answers, Remove a
Facility, Restart Client Counts)
* Information from asterisked (*) questions may be published on FindTreatment.gov
(https://findtreatment.gov) in SAMHSA’s National Directory of Drug and Alcohol Use Treatment
Facilities and the National Directory of Mental Health Treatment Facilities, and other publiclyavailable listings, unless you designate otherwise in question C8 of this questionnaire.
148
RESPONDENT INFORMATION
E1. Your survey is almost complete. Please confirm the facility information below.
Please carefully review the information for each of the listed facilities and update as needed.
149
E2. Your survey is almost complete. Please confirm the facility information below.
Who is the director of each facility?
This information will only be used if we need to contact you about your responses. It will not be published.
150
E3. Who is primarily responsible for completing this questionnaire?
This information will only be used if we need to contact you about your responses. It will not be published.
Select One
o Ms.
o Mr.
o Mrs.
o Dr.
o Other (Specify:_______)
First Name:
________________________________
Middle Initial
________________________________
Last Name
________________________________
Title:
________________________________
Telephone:
________________________________
Ext
________________________________
Is this a cell phone
o Yes
Can we text you at this number?
o Yes
Fax:
________________________________
Email Address:
________________________________
151
| File Type | application/pdf |
| File Modified | 2023-08-14 |
| File Created | 2023-08-14 |