Revised Privacy Protection Statement

U.S. Department of Health and Human Services

FORM APPROVED:

OMB No. 0930-XXXX

APPROVAL EXPIRES: XX/XX/XXXX

See OMB burden statement on last page

PLEASE REVIEW THE FACILITY INFORMATION PRINTED ABOVE.

CROSS OUT ERRORS AND ENTER CORRECT OR MISSING INFORMATION.

CHECK ONE

 Information is complete and correct, no changes needed

 All missing or incorrect information has been corrected

prepared by mathematica policy research, inc.

PLEASE READ THIS ENTIRE PAGE BEFORE COMPLETING THE QUESTIONNAIRE

INSTRUCTIONS

• Most of the questions in this survey ask about “this facility.” By “this facility” we mean the specific treatment facility or program whose name and location are printed on the front cover. If you have any questions about how the term “this facility” applies to your facility, please call 1-888-324-8337.

• Please answer ONLY for the specific facility or program whose name and location are printed on the front cover, unless otherwise specified in the questionnaire.

• Return the completed questionnaire in the envelope provided. Please keep a copy for your records.

• For additional information about this survey or the types of care referred to in the questionnaire, please visit our website at http://info.nssats.com.

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

MATHEMATICA POLICY RESEARCH, INC.

1-888-324-8337

If you prefer, you may complete this questionnaire online. See the pink flyer enclosed in your questionnaire packet for the Internet address and your unique user ID and password. If you need more information, call the N-SSATS helpline at 1-888-324-8337.

IMPORTANT INFORMATION

_* Asterisked questions. Information from asterisked (_*) questions will be published in SAMHSA’s National Directory of Drug and Alcohol Abuse Treatment Programs and will be available online at http://findtreatment.samhsa.gov, SAMHSA’s Substance Abuse Treatment Facility Locator.

Mapping feature in Locator. Complete and accurate name and address information is needed for the online Treatment Facility Locator so it can correctly map the facility location.

Eligibility for Directory/Locator. Only facilities designated as eligible by their state substance abuse office will be listed in the National Directory and online Treatment Facility Locator. Your state N-SSATS representative can tell you if your facility is eligible to be listed in the Directory/Locator. For the name and telephone number of your state representative, call the N‑SSATS helpline at 1-888-324-8337 or go to http://wwwdasis.samhsa.gov and click on “DASIS Contacts” then “N-SSATS Contacts by State.”

prepared by mathematica policy research, inc.

SECTION A: FACILITY

CHARACTERISTICS

Section A asks about characteristics of individual facilities and should be completed for this facility only, that is, the treatment facility or program at the location listed on the front cover.

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

MARK “YES” OR “NO” FOR EACH

YES NO

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

2. Detoxification 1  0 

3. Substance abuse treatment

(services that focus on initiating

and maintaining an individual’s

recovery from substance abuse

and on averting relapse) 1  0 

4. Any other substance abuse

services 1  0 

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

1  Yes

0  No SKIP TO Q.3 (TOP OF NEXT COLUMN)

2a. Does this facility detoxify clients from . . .

MARK “YES” OR “NO” FOR EACH

YES NO

1. Alcohol 1  0 

2. Opiates 1  0 

3. Cocaine 1  0 

4. Other (Specify: 1  0 

)

2b. Does this facility routinely use medications during detoxification?

1  Yes

0  No

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

1  Yes

0  No SKIP TO Q.41 (PAGE 12)

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

MARK ONE ONLY

1  Substance abuse treatment services

2  Mental health services

3  Mix of mental health and substance abuse

treatment services (neither is primary)

4  General health care

5  Other (Specify: )

5. Is this facility operated by . . .

MARK ONE ONLY

1  A private for-profit organization

SKIP TO

Q.6

(PAGE 2)

2  A private non-profit organization

3  State government

4  Local, county, or community

government

5  Tribal government

6  Federal government

5a. Which federal government agency?

MARK ONE ONLY

1  Department of Veterans Affairs

2  Department of Defense

SKIP TO

Q.8

(PAGE 2)

3  Indian Health Service

4  Other (Specify: )

6. Is this facility a solo practice, meaning, an office with a single practitioner or therapist?

1  Yes

0  No

7. Is this facility affiliated with a religious organization?

1  Yes

0  No

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

1  Yes SKIP TO Q.47 (PAGE 12)

0  No

9. Is this facility located in, or operated by, a hospital?

1  Yes

0  No SKIP TO Q.10 (TOP OF NEXT COLUMN)

9a. What type of hospital?

MARK ONE ONLY

1  General hospital (including VA hospital)

2  Psychiatric hospital

3  Other specialty hospital, for example,

alcoholism, maternity, etc.

(Specify: )

*10. What telephone number(s) should a potential client call to schedule an intake appointment?

INTAKE TELEPHONE NUMBER(S)

1. (______) ________ - ___________ ext._____

2. (______) ________ - ___________ ext._____

11. Does this facility operate a hotline that responds to substance abuse problems?

• A hotline is a telephone service that provides information, referral, or immediate counseling, frequently in a crisis situation.

• If this facility is part of a group of facilities that operates a central hotline to respond to substance abuse problems, you should mark “yes.”

• DO NOT consider 911 or the local police number

a hotline for the purpose of this survey.

1  Yes

0  No SKIP TO Q.12 (PAGE 3)

*11a. Please enter the hotline telephone number(s) below.

HOTLINE TELEPHONE NUMBER(S)

1. (______) ________ - ___________ ext._____

2. (______) ________ - ___________ ext._____

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

MARK ALL THAT APPLY

Assessment and Pre-Treatment Services

1  Screening for substance abuse

2  Screening for mental health disorders

3  Comprehensive substance abuse assessment

or diagnosis

4  Comprehensive mental health assessment or

diagnosis (for example, psychological or

psychiatric evaluation and testing)

5  Outreach to persons in the community that

may need treatment

6  Interim services for clients when immediate

admission is not possible

Pharmacotherapies

7  Antabuse

8  Naltrexone

9  Campral

10  Buprenorphine – Subutex

11  Buprenorphine – Suboxone

12  Methadone

13  Nicotine replacement

14  Medications for psychiatric disorders

Testing (Include tests performed at this location,

even if specimen is sent to an outside source for

chemical analysis.)

15  Breathalyzer or other blood alcohol testing

16  Drug or alcohol urine screening

17  Screening for Hepatitis B

18  Screening for Hepatitis C

19  HIV testing

20  STD testing

21  TB screening

Transitional Services

22  Discharge planning

23  Aftercare/continuing care

Ancillary Services

24  Case management services

25  Social skills development

26  Mentoring/peer support

27  Child care for clients’ children

28  Assistance with obtaining social services

(for example, Medicaid, WIC, SSI, SSDI)

29  Employment counseling or training for clients

30  Assistance in locating housing for clients

31  Domestic violence—family or partner violence

services (physical, sexual, and emotional

abuse)

32  Early intervention for HIV

33  HIV or AIDS education, counseling, or support

34  Health education other than HIV/AIDS

35  Substance abuse education

36  Transportation assistance to treatment

37  Mental health services

38  Acupuncture

* 39  Residential beds for clients’ children

40  Self-help groups (for example, AA, NA,

Smart Recovery)

13. As part of substance abuse treatment, does this facility employ individual counseling?

1  Yes

0  No SKIP TO Q.14 (BELOW)

13a. What percent of substance abuse clients receive individual counseling?

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

%

14. As part of substance abuse treatment, does this facility employ group counseling (with peers)?

1  Yes

0  No SKIP TO Q.15 (TOP OF PAGE 4)

14a. What percent of substance abuse clients receive group counseling?

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

%

15. As part of substance abuse treatment, does this facility employ family counseling?

1  Yes

0  No SKIP TO Q.16 (BELOW)

15a. What percent of substance abuse clients receive family counseling?

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

%

16. As part of substance abuse treatment, does this facility employ marital/couples counseling?

1  Yes

0  No SKIP TO Q.17 (TOP OF NEXT COLUMN)

16a. What percentage of substance abuse clients receive marital/couples counseling?

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

%

17. Are any of the following practices part of this facility’s standard operating procedures?

MARK “YES” OR “NO” FOR EACH

YES NO

1. Required continuing education

for staff 1  0 

2. Periodic drug testing of clients 1  0 

3. Regularly scheduled case

review with a supervisor 1  0 

4. Case review by an appointed

quality review committee 1  0 

5. Outcome follow-up after discharge 1  0 

6. Periodic utilization review 1  0 

7. Periodic client satisfaction

surveys conducted by the facility 1  0 

18. Listed below are a variety of clinical/therapeutic approaches used by substance abuse treatment facilities. For each, please mark the box that best describes how often the practice is used at this facility.

	MARK ONE FREQUENCY FOR EACH
	Never	Rarely	Sometimes	Often	Not Familiar With This Approach
1. Substance abuse counseling	1 	2 	3 	4 	5 
2. 12-step approach	1 	2 	3 	4 	5 
3. Brief intervention	1 	2 	3 	4 	5 
4. Cognitive-behavioral therapy	1 	2 	3 	4 	5 
5. Contingency management	1 	2 	3 	4 	5 
6. Motivational interviewing	1 	2 	3 	4 	5 
7. Trauma-related counseling	1 	2 	3 	4 	5 
8. Anger management	1 	2 	3 	4 	5 
9. Relapse prevention	1 	2 	3 	4 	5 
10. Other treatment approach (Specify: )	1 	2 	3 	4 	5 

*19. Does this facility operate a methadone maintenance or detoxification program at this location?

1  Yes

0  No SKIP TO Q.20 (BELOW)

*19a. Is the methadone program at this location a maintenance program, a detoxification program, or both?

MARK ONE ONLY

1  Maintenance program

2  Detoxification program

3  Both

*19b. Are ALL of the substance abuse clients at this facility currently in the methadone program?

1  Yes

0  No

*20. Does this facility offer a special program for DUI/DWI or other drunk driver offenders at this location?

• Mark “yes” if this facility serves only DUI/DWI clients OR if this facility has a special DUI/DWI program.

1  Yes

0  No SKIP TO Q.21 (BELOW)

*20a. Does this facility serve only DUI/DWI clients?

1  Yes

0  No

*21. Does this facility provide substance abuse treatment services in sign language (for example, American Sign Language, Signed English, or Cued Speech) for the hearing impaired at this location?

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

1  Yes

0  No

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

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

1  Yes

0  No SKIP TO Q.23 (PAGE 6)

22a. At this facility, who provides substance abuse treatment services in a language other than English?

MARK ONE ONLY

1  Staff counselor who speaks a language

other than English GO TO Q.22b (BELOW)

2  On-call interpreter (in person or by phone)

brought in when needed SKIP TO Q.23

(PAGE 6)

3  BOTH staff counselor and on-call

interpreter GO TO Q.22b (BELOW)

*22b. In what other languages do staff counselors provide substance abuse treatment at this facility?

MARK ALL THAT APPLY

American Indian or Alaska Native:

1  Hopi 3  Navajo

2  Lakota 4  Yupik

5  Other American Indian or

Alaska Native language

(Specify: )

Other Languages:

6  Arabic 12  Korean

7  Chinese 13  Polish

8  Creole 14  Portuguese

9  French 15  Russian

10  German 16  Spanish

11  Hmong 17  Vietnamese

18  Other language (Specify:

)

*23. This question has two parts. Column A asks about the types of clients accepted into treatment at this facility. Column B asks whether this facility offers specially designed treatment programs or groups for each type of client.

Column A - For each type of client listed below: Indicate whether this facility accepts these clients into treatment at this location.

Column B - For each “yes” in Column A: Indicate whether this facility offers a specially designed substance abuse treatment program or group exclusively for that type of client at this location.

	Column A		Column B
Type of Client	Clients Accepted Into Treatment		Offers Specially Designed Program or Group
	YES	NO	YES	NO
1. Adolescents	1 	0 	1 	0 
2. Clients with co‑occurring mental and substance abuse disorders	1 	0 	1 	0 
3. Criminal justice clients (other than dui/dwi)	1 	0 	1 	0 
4. Persons with hiv or aids	1 	0 	1 	0 
5. Gays or lesbians	1 	0 	1 	0 
6. Seniors or older adults	1 	0 	1 	0 
7. Adult women	1 	0 	1 	0 
8. Pregnant or postpartum women	1 	0 	1 	0 
9. Adult men	1 	0 	1 	0 
10. Specially designed programs or groups for any other types of clients (Specify:			1 	0 
)

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

MARK “YES” OR “NO” FOR EACH

YES NO

1. Hospital inpatient detoxification 1  0 

(Similar to ASAM Levels IV-D

and III.7-D, medically managed or

monitored inpatient detoxification)

2. Hospital inpatient treatment 1  0 

(Similar to ASAM Levels IV and III.7,

medically managed or monitored

intensive inpatient treatment)

NOTE: ASAM is the American Society of Addiction Medicine.

*25. Does this facility offer any of the following RESIDENTIAL (non-hospital) substance abuse services at this location, that is, the location listed on the front cover?

MARK “YES” OR “NO” FOR EACH

YES NO

1. Residential detoxification 1 ¨ 0 ¨

(Similar to ASAM Level III.2-D,

clinically managed residential

detoxification or social detoxification)

2. Residential short-term treatment 1 ¨ 0 ¨

(Similar to ASAM Level III.5,

clinically managed high-intensity

residential treatment; typically

30 days or less)

3. Residential long-term treatment 1 ¨ 0 ¨

(Similar to ASAM Levels III.3

and III.1, clinically managed medium-

or low-intensity residential treatment;

typically more than 30 days)

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

MARK “YES” OR “NO” FOR EACH

YES NO

1. Outpatient detoxification 1 ¨ 0 ¨

(Similar to ASAM Levels I-D and II-D,

ambulatory detoxification)

2. Outpatient methadone/

buprenorphine maintenance 1 ¨ 0 ¨

(Opioid maintenance therapy)

3. Outpatient day treatment or

partial hospitalization 1 ¨ 0 ¨

(Similar to ASAM Level II.5,

20 or more hours per week)

4. Intensive outpatient treatment 1 ¨ 0 ¨

(Similar to ASAM Level II.1,

9 or more hours per week)

5. Regular outpatient treatment 1 ¨ 0 ¨

(Similar to ASAM Level I,

outpatient treatment;

non-intensive)

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

1  Yes

0  No SKIP TO Q.28 (TOP OF NEXT COLUMN)

27a. Do you want the availability of a sliding fee

scale published in SAMHSA’s Directory/Locator?

(For information on Directory/Locator eligibility, see the inside front cover.)

• The Directory/Locator will explain that sliding fee scales are based on income and other factors.

1  Yes

0  No

*28. Does this facility offer treatment at no charge to clients who cannot afford to pay?

1  Yes

0  No SKIP TO Q.29 (BELOW)

28a. Do you want the availability of free care for eligible clients published in SAMHSA’s

Directory/Locator?

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

1  Yes

0  No

29. Does this facility receive any funding or grants from the Federal government, or state, county or local governments, to support its substance abuse treatment programs?

• Do not include Medicare, Medicaid, or federal military insurance. These forms of client payments will be included in Q.30 below.

1 ¨ Yes

0 ¨ No

-1 ¨ Don’t Know

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

MARK “YES,” “NO,” OR “DON’T KNOW” FOR EACH

DON’T

YES NO KNOW

1. No payment accepted (free

treatment for ALL clients) 1 ¨ 0 ¨ -1 ¨

2. Cash or self-payment 1 ¨ 0 ¨ -1 ¨

3. Medicare 1 ¨ 0 ¨ -1 ¨

4. Medicaid 1 ¨ 0 ¨ -1 ¨

5. A state-financed health

insurance plan other than

Medicaid (for example, State

Children’s Health Insurance

Program (SCHIP) or high risk

insurance pools) 1 ¨ 0 ¨ -1 ¨

6. Federal military insurance such

as TRICARE or Champ VA 1 ¨ 0 ¨ -1 ¨

7. Private health insurance 1 ¨ 0 ¨ -1 ¨

8. Access To Recovery (ATR)

vouchers (to be answered

by facilities in the following

states only: CA, CT, FL, ID,

IL, LA, MO, NJ, NM, TN, TX,

WA, WI, WY) 1 ¨ 0 ¨ -1 ¨

9. Other 1 ¨ 0 ¨ -1 ¨

(Specify: )

31. Does this facility have agreements or contracts with managed care organizations for providing substance abuse treatment services?

• Managed care organizations have agreements with certain health care providers who give services to plan members, usually at discounted rates. Examples include managed behavioral healthcare organizations (MBHOs), health maintenance organizations (HMOs), and preferred provider organizations (PPOs).

1 ¨ Yes

0 ¨ No

-1 ¨ Don’t Know

SECTION B: CLIENT COUNT

INFORMATION

32. Q

important: Questions in Section B ask about different time periods, e.g., the single day of March 30, 2007, and the 12-month period ending on March 31, 2007. Please pay special attention to the period specified in each question.

IF THIS IS A MENTAL HEALTH FACILITY: Include in your client counts all clients receiving substance abuse treatment, even if substance abuse is their secondary diagnosis.

uestions 33 through 38 ask about the number of clients in treatment at this facility at specified times.

Please check the option below that best describes how client counts will be reported in these questions.

MARK ONE ONLY

1 ¨ Questions 33 through 38 will

include client counts for this facility

alone SKIP TO Q.33 (TOP OF

NEXT COLUMN)

2 ¨ Questions 33 through 38 will

include client counts for this

facility combined with other

facilities SKIP TO Q.33 (TOP OF

NEXT COLUMN)

3 ¨ Client counts for this facility

will be reported by another

facility SKIP TO Q.41 (PAGE 12)

3

hospital inpatient

3. On March 30, 2007, did any patients receive HOSPITAL INPATIENT substance abuse services at this facility?

1 ¨ Yes

0 ¨ No SKIP TO Q.34 (PAGE 9)

33a. On March 30, 2007, how many patients received the following HOSPITAL INPATIENT substance abuse services at this facility?

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

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

ENTER A NUMBER FOR EACH

(IF NONE, ENTER “0”)

1. Hospital inpatient detoxification ___________

(Similar to ASAM Levels IV-D

and III.7-D, medically managed or

monitored inpatient detoxification)

2. Hospital inpatient treatment ___________

(Similar to ASAM Levels IV and III.7,

medically managed or monitored

intensive inpatient treatment)

HOSPITAL INPATIENT TOTAL BOX

33b. How many of the patients from the HOSPITAL INPATIENT TOTAL BOX were under the age of 18?

ENTER A NUMBER

(IF NONE, ENTER “0”)

Number under age 18 _____________

33c. How many of the patients from the HOSPITAL INPATIENT TOTAL BOX received methadone or buprenorphine dispensed by this facility?

• Include patients who received these drugs for detoxification or maintenance purposes.

ENTER A NUMBER FOR EACH

(IF NONE, ENTER “0”)

1. Methadone _______________

2. Buprenorphine _______________

33d. On March 30, 2007, how many hospital inpatient beds at this facility were specifically designated for substance abuse treatment?

ENTER A NUMBER

(IF NONE, ENTER “0”)

Number of beds _______________

residential (non-hospital)

34. On March 30, 2007, did any clients receive RESIDENTIAL (non‑hospital) substance abuse services at this facility?

1 ¨ Yes

0 ¨ No SKIP TO Q.35 (PAGE 10)

34a. On March 30, 2007, how many clients received the following RESIDENTIAL substance abuse services at this facility?

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

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

ENTER A NUMBER FOR EACH

(IF NONE, ENTER “0”)

1. Residential detoxification _____________

(Similar to ASAM Level III.2-D,

clinically managed residential

detoxification or social detoxification)

2. Residential short-term treatment _____________

(Similar to ASAM Level III.5,

clinically managed high-intensity

residential treatment; typically

30 days or less)

3. Residential long-term treatment _____________

(Similar to ASAM Levels III.3

and III.1, clinically managed medium-

or low-intensity residential treatment;

typically more than 30 days)

RESIDENTIAL TOTAL BOX

34b. How many of the clients from the RESIDENTIAL TOTAL BOX were under the age of 18?

ENTER A NUMBER

(IF NONE, ENTER “0”)

Number under age 18 _______________

34c. How many of the clients from the RESIDENTIAL TOTAL BOX received methadone or buprenorphine dispensed by this facility?

• Include clients who received these drugs for detoxification or maintenance purposes.

ENTER A NUMBER FOR EACH

(IF NONE, ENTER “0”)

1. Methadone _______________

2. Buprenorphine _______________

34d. On March 30, 2007, how many residential beds at this facility were specifically designated for substance abuse treatment?

ENTER A NUMBER

(IF NONE, ENTER “0”)

Number of beds _______________

3

outpatient

5. During the month of March 2007, did any clients receive OUTPATIENT substance abuse services at this facility?

1 ¨ Yes

0 ¨ No SKIP TO Q.36 (PAGE 11)

35a. As of March 30, 2007, how many active clients were enrolled in each of the following OUTPATIENT substance abuse services at this facility?

An active outpatient client is someone who:

(1) was seen at this facility for substance abuse treatment or detoxification at least once during the month of March 2007

AND

(2) was still enrolled in treatment on

March 30, 2007.

• count a client in one service only, even if

the client received multiple services.

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

ENTER A NUMBER FOR EACH

(IF NONE, ENTER “0”)

1. Outpatient detoxification _____________

(Similar to ASAM

Levels I-D and II-D,

ambulatory detoxification)

2. Outpatient methadone/

buprenorphine maintenance _____________

(Opioid maintenance therapy)

3. Outpatient day treatment or

partial hospitalization _____________

(Similar to ASAM Level II.5,

20 or more hours per week)

4. Intensive outpatient treatment _____________

(Similar to ASAM Level II.1,

9 or more hours per week)

5. Regular outpatient treatment _____________

(Similar to ASAM Level I,

outpatient treatment;

non-intensive)

OUTPATIENT TOTAL BOX

35b. How many of the clients from the OUTPATIENT TOTAL BOX were under the age of 18?

ENTER A NUMBER

(IF NONE, ENTER “0”)

Number under age 18 _______________

35c. How many of the clients from the OUTPATIENT TOTAL BOX received methadone or buprenorphine dispensed by this facility?

• Include clients who received these drugs for detoxification or maintenance purposes.

ENTER A NUMBER FOR EACH

(IF NONE, ENTER “0”)

1. Methadone _______________

2. Buprenorphine _______________

35d. Without adding to the staff or space available in March 2007, what is the maximum number of clients who could have been enrolled in outpatient substance abuse treatment on March 30, 2007? This is generally referred to as outpatient capacity.

OUTPATIENT CAPACITY ON MARCH 30, 2007

This number should not be less than the number entered in the OUTPATIENT TOTAL BOX.

36. Some clients are treated for both alcohol and drug abuse, while others are treated for only alcohol or only drug abuse. Approximately what percent of the substance abuse treatment clients enrolled at this facility on March 30, 2007, including hospital inpatient, residential, and/or outpatient, were being treated for . . .

1. BOTH alcohol AND

drug abuse ___________%

2. ONLY alcohol abuse ___________%

3. ONLY drug abuse ___________%

TOTAL

%

37. Approximately what percent of the substance abuse treatment clients enrolled at this facility on March 30, 2007, had a diagnosed co-occurring substance abuse and mental health disorder?

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

%

38. In the 12 months beginning April 1, 2006, and ending March 31, 2007, how many ADMISSIONS for substance abuse treatment did this facility have? Count every admission and re‑admission in this 12‑month period. If a person was admitted 3 times, count this as 3 admissions.

• FOR OUTPATIENT CLIENTS, consider an admission to be the initiation of a treatment program or course of treatment. Count admissions into treatment, not individual treatment visits.

• IF DATA FOR THIS TIME PERIOD are not available, use the most recent 12-month period for which you have data.

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

NUMBER OF SUBSTANCE ABUSE ADMISSIONS IN 12-MONTH PERIOD

38a. How many of the 12-month treatment admissions included in question 38 were funded by ATR vouchers?

• To be answered by facilities in the following states only: CA, CT, FL, ID, IL, LA, MO, NJ, NM, TN, TX, WA, WI, WY

NUMBER OF ADMISSIONS FUNDED BY ATR VOUCHERS (IF NONE, ENTER “0”)

39. How many facilities are included in the client counts reported in questions 33 through 38?

1 ¨ Only this facility SKIP TO Q.40 (BELOW)

2 ¨ This facility plus others ENTER NUMBER OF

FACILITIES INCLUDED

IN CLIENT COUNTS:

1

THIS FACILITY

+ ADDITIONAL FACILITIES

= TOTAL FACILITIES

When we receive your questionnaire, we will contact you for a list of the other facilities included in your client counts.

If you prefer, attach a separate piece of paper listing the name and location address of each facility included in your client counts.

Please continue with Question 40 (BELOW)

40. For which of the numbers you just reported did you provide actual client counts and for which did you provide your best estimate?

• Mark “N/A” for any type of care not provided by this facility on March 30, 2007.

MARK “ACTUAL,” “ESTIMATE,” OR “N/A” FOR EACH

actual estimate n/a

1. Hospital inpatient clients

(Q.33a, Pg. 8) 1 ¨ 2 ¨ - 4 ¨

2. Residential clients

(Q.34a, Pg. 9) 1 ¨ 2 ¨ - 4 ¨

3. Outpatient clients

(Q.35a, Pg. 10) 1 ¨ 2 ¨ - 4 ¨

4. 12-month admissions

(Q.38) 1 ¨ 2 ¨ - 4 ¨

SECTION C:

GENERAL INFORMATION

Section C should be completed for this facility only.

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

1 ¨ Yes

0 ¨ No

42. Does this facility or program have licensing, certification, or accreditation from any of the following organizations?

• Only include facility-level licensing, accreditation, etc., related to the provision of substance abuse services.

• Do not include general business licenses, fire marshal approvals, personal‑level credentials, food service licenses, etc.

MARK “YES,” “NO,” OR “DON’T KNOW” FOR EACH

DON’T

YES NO KNOW

1. State substance abuse agency 1 ¨ 0 ¨ -1 ¨

2. State mental health department 1 ¨ 0 ¨ -1 ¨

3. State department of health 1 ¨ 0 ¨ -1 ¨

4. Hospital licensing authority 1 ¨ 0 ¨ -1 ¨

5. JCAHO (Joint Commission

on Accreditation of Healthcare

Organizations) 1 ¨ 0 ¨ -1 ¨

6. CARF (Commission on Accreditation

of Rehabilitation Facilities) 1 ¨ 0 ¨ -1 ¨

7. ncqa (National Committee

for Quality Assurance) 1 ¨ 0 ¨ -1 ¨

8. coa (Council on Accreditation for

Children & Family Services) 1 ¨ 0 ¨ -1 ¨

9. Another state or local agency or

other organization 1 ¨ 0 ¨ -1 ¨

(Specify: )

43. Has this facility received a National Provider Identifier (NPI)?

1 ¨ Yes

0 ¨ No SKIP TO Q.44 (BELOW)

43a. What is the NPI for this facility?

NPI

* 44. Does this facility have a website or web page with information about the facility’s substance abuse treatment programs?

1 ¨ Yes

Please check the front cover of this questionnaire to confirm that the website address for this facility is correct EXACTLY as listed. If incorrect or missing, enter the correct address.

0 ¨ No

45. If eligible, does this facility want to be listed in the National Directory and Online Treatment Facility Locator? (See inside front cover for eligibility information.)

1 ¨ Yes

0 ¨ No

46. Would you like to receive a free paper copy of the next National Directory of Drug and Alcohol Abuse Treatment Programs when it is published?

1 ¨ Yes

0 ¨ No

47. Who was primarily responsible for completing this form? This information will only be used if we need to contact you about your responses. It will not be published.

Name:

Title:

Phone Number: (_____) - _______ -

Fax Number: (_____) - _______ -

Email Address:

NOTES

Pledge to respondents

The information you provide will be protected to the fullest extent allowable under the Public Health Service Act, 42 USC Sec 501. 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 eligible treatment facilities, information provided in response to survey questions marked with an asterisk will be published in SAMHSA’s National Directory of Drug and Alcohol Abuse Treatment Programs and the Substance Abuse Treatment Facility Locator. Responses to non-asterisked questions will be published only in statistical summaries so that individual treatment facilities cannot be identified.

Thank you for your participation. Please return this questionnaire in the envelope provided.

If you no longer have the envelope, please mail this questionnaire to:

MATHEMATICA POLICY RESEARCH, INC.

ATTN: RECEIPT CONTROL - Project 8945

P.O. Box 2393

Princeton, NJ 08543-2393

Public burden for this collection of information is estimated to average 40 minutes per response 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, Room 7-1044, 1 Choke Cherry Road, Rockville, MD 20857. 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 number for this project is 0930-XXXX.

Prepared by Mathematica Policy Research, Inc.