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pdfU.S. Department of Health and Human Services
OMB No. 0930-0119
APPROVAL EXPIRES: 02/28/2017
See OMB burden statement on last page
2016 National Mental Health Services
Survey
(N-MHSS)
April 29, 2016
Substance Abuse and Mental Health Services Administration (SAMHSA)
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
PLEASE READ THIS ENTIRE PAGE BEFORE
COMPLETING THE QUESTIONNAIRE
Would you prefer to complete this questionnaire online? See the green flyer enclosed in your
questionnaire packet for the Internet address and your unique User ID and Password. You can log on and
off the survey website as often as needed to complete the questionnaire. When you log on again, the
program will take you to the next unanswered question. If you need additional help or information, call the
N-MHSS helpline at 1-866-778-9752.
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 1-866-778-9752.
•
Please answer ONLY for the specific facility or program whose name and location are printed on
the front cover, unless otherwise specified in the questionnaire.
•
If this is a separate inpatient psychiatric unit of a general hospital, consider the psychiatric unit
as the relevant “facility” for the purpose of this survey.
•
For additional information about the survey and definitions for some of the terms, please visit our
website at: https://info.nmhss.org.
•
Return the completed questionnaire in the envelope provided, or fax it to 1-609-799-0005. (Please
reference “N-MHSS” on your fax.)
Please keep a copy of your completed questionnaire for your records.
•
If you have questions or need additional blank forms, contact:
MATHEMATICA POLICY RESEARCH
1-866-778-9752
NMHSS@mathematica-mpr.com
IMPORTANT INFORMATION
*Asterisked Questions. Information from asterisked (*) questions is published in SAMHSA’s online
Behavioral Health Treatment Services Locator, found at https://findtreatment.samhsa.gov, unless you
designate otherwise in question C1, page 6, of this questionnaire.
Mapping Feature in online Locator. Complete and accurate name and address information is
needed for SAMHSA’s online Behavioral Health Treatment Services Locator so it can correctly map
the facility’s location.
Eligibility for online Locator. Only facilities that provide mental health treatment and complete this
questionnaire are eligible to be listed in the online Behavioral Health Treatment Services Locator. If
you have any questions regarding eligibility, please contact the N-MHSS helpline at 1-866-778-9752.
*A4.
SECTION A: FACILITY
CHARACTERISTICS
• For definitions of facility types, go to:
https://info.nmhss.org
MARK ONE ONLY
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.
A1.
2. Mental health diagnostic evaluation...... 1
0
3. Mental health information and/or .......... 1
0
0
*A3.
SKIP
TO
A7
(NEXT
PAGE)
Veterans Administration medical center
(VAMC) or other VA health care facility
7
Community mental health center (CMHC)
8
Partial hospitalization/day treatment facility
9
Outpatient mental health facility
Multi-setting mental health facility (nonhospital residential plus either outpatient
and/or partial hospitalization/day
treatment)
Other (Specify:
)
A5.
treatment facilities ................................. 1
0
0
A5a.
Did you answer “yes” to mental health treatment
in question A1 above (option 4)?
No
Other type of residential treatment
6
6. Administrative services for mental health
0
5
11
5. Substance abuse treatment ................. 1
Yes
Residential treatment center for adults
(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)
Residential treatment center for
4
10
*4. Mental health treatment ........................ 1
1
Separate inpatient psychiatric unit of a
facility
referral (also includes emergency
programs that provide services in
person or by telephone)
A2.
2
children
NO
0
Psychiatric hospital
3
MARK “YES” OR “NO” FOR EACH
1. Mental health intake .............................. 1
1
general hospital (consider this
psychiatric unit as the relevant “facility”
for the purpose of this survey)
Does this treatment facility, at this location, offer:
YES
Which ONE category BEST describes this
facility, at this location?
Is this facility a solo or a small group practice?
1
Yes
0
No
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.
1
Yes
0
No
SKIP TO C4 (PAGE 6)
Mental health treatment is provided in which of
the following service settings at this facility, at
this location?
A6.
•
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.nmhss.org
YES NO
0
2. 24-hour residential ................................ 1
0
0
0
3. Partial hospitalization/
day treatment ......................................... 1
4. Outpatient ............................................. 1
SKIP TO C4 (PAGE 6)
Is this facility a Federally Qualified Health Center
(FQHC)?
MARK “YES” OR “NO” FOR EACH
1. 24-hour hospital inpatient ..................... 1
SKIP TO A6 (BELOW)
Yes
0 No
d Don’t know
1
1
A7.
What is the primary treatment focus of this
facility, at this location?
• Separate psychiatric units in general hospitals
should answer for just their unit and NOT for the
entire hospital.
*A10. Which of these mental health treatment
approaches are offered at this facility, at
this location?
• For definitions of treatment approaches, go to:
https://info.nmhss.org
MARK ONE ONLY
MARK ALL THAT APPLY
1
Mental health treatment
Substance abuse
treatment
SKIP TO C4 (PAGE 6)
1
2
Individual psychotherapy
2
Couples/family therapy
3
Mix of mental health and substance abuse
treatment (neither is primary)
3
Group therapy
4
Cognitive behavioral therapy
4
General health care
5
Dialectical behavior therapy
5
Other service focus (Specify:
6
Behavior modification
7
Integrated dual disorders treatment
8
Trauma therapy
9
Activity therapy
)
A8.
Is this facility a jail, prison, or detention center
that provides treatment exclusively for
incarcerated persons or juvenile detainees?
1
Yes
0
No
10
Electroconvulsive therapy
11
Telemedicine therapy
12
Psychotropic medication
13
Other (Specify:
SKIP TO C4 (PAGE 6)
)
*A9.
Is this facility operated by:
14
approaches are offered
MARK ONE ONLY
1
A private for-profit organization
2
A private non-profit organization
3
A public agency or department
SKIP TO A10
(NEXT
COLUMN)
*A9a. Which public agency or department?
MARK ONE ONLY
1
State mental health authority (SMHA)
2
Other state government agency or department
(e.g., Department of Health)
3
Regional/district authority or county, local, or
municipal government
4
Tribal government
5
Indian Health Service
6
Department of Veterans Affairs
7
Other (Specify:
)
2
None of these mental health treatment
*A11. Which of these services and practices are
offered at this facility, at this location?
*A12. What age groups are accepted for treatment
at this facility?
• For definitions, go to: https://info.nmhss.org
MARK “YES” OR “NO” FOR EACH
YES
Children (12 or younger) .................... 1
Adolescents (13-17) ........................... 1
Young adults (18-25) .......................... 1
Adults (26-64) ..................................... 1
Seniors (65 or older) ........................... 1
MARK ALL THAT APPLY
1.
1
Assertive community treatment (ACT)
2
Intensive case management (ICM)
3
Case management (CM)
4.
4
Court-ordered outpatient treatment
5.
5
Chronic disease/illness management (CDM)
6
Illness management and recovery (IMR)
7
Integrated primary care services
8
Diet and exercise counseling
9
Family psychoeducation
2.
3.
NO
0
0
0
0
0
*A13. Does this facility offer a mental health treatment
program or group that is dedicated or designed
exclusively for clients in any of the following
categories?
• If this facility treats clients in any of these
categories, but does not have a specifically
tailored program or group for them, DO NOT
mark the box for that category.
MARK ALL THAT APPLY
1
Children/adolescents with serious emotional
disturbance (SED)
2
Transitional age young adults
3
Persons 18 and older with serious mental
illness (SMI)
Vocational rehabilitation services
4
Seniors or older adults
Supported employment
5
Persons with Alzheimer’s or dementia
6
Persons with co-occurring mental
and substance use disorders
10
Education services
11
Housing services
12
Supported housing
13
Psychosocial rehabilitation services
14
15
16
Therapeutic foster care
17
Legal advocacy
7
Persons with eating disorders
18
Psychiatric emergency walk-in services
8
Persons with a diagnosis of post-traumatic
stress disorder (PTSD)
19
Suicide prevention services
9
20
Consumer-run (peer support) services
Persons who have experienced trauma
(excluding persons with a PTSD diagnosis)
10
Persons with traumatic brain injury (TBI)
21
Screening for tobacco use
11
Veterans
22
Smoking/tobacco cessation counseling
12
Active duty military
23
Nicotine replacement therapy
13
Members of military families
24
Non-nicotine smoking/tobacco cessation
medications (by prescription)
14
Lesbian, gay, bisexual, or transgender
clients (LGBT)
15
Forensic clients (referred from the court/
judicial system)
16
Persons with HIV or AIDS
17
Other special program or group (Specify:
25
Other (Specify:
)
26
)
None of these services and practices are offered
18
No dedicated or exclusively designed programs
or groups are offered
3
*A14. Does this facility offer a crisis intervention team
that handles acute mental health issues at this
facility and/or off-site?
*A16b. In what other languages do staff provide mental
health treatment services at this facility?
• Do not count languages provided only by on-call
interpreters.
1
Yes
MARK ALL THAT APPLY
0
No
American Indian or Alaska Native:
*A15. 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)?
1
Yes
0
No
3
6
1
2
____________________________________)
Other Languages:
8
9
10
11
12
13
14
15
25
7
*A16. Does this facility provide mental health treatment
services in a language other than English at this
location?
1
Yes
0
No, only English
SKIP TO A17
(NEXT COLUMN)
A16a. At this facility, who provides mental health
treatment services in a language other than
English?
MARK ONE ONLY
1
Staff who speak a language other than English
2
On-call interpreter (in person or by phone)
brought in when needed
SKIP TO A17
(NEXT COLUMN)
3
BOTH staff and on-call interpreter
*A16a1. Do staff provide mental health treatment
services in Spanish at this facility?
1
Yes
0
No
Hopi
4 Ojibwa
Lakota
5 Yupik
Navajo
Other American Indian or Alaska Native
Language (Specify:
Arabic
16
Any Chinese Language 17
Creole
18
Farsi
19
French
20
German
21
Greek
22
Hebrew
23
Hindi
24
Any other language (Specify:
Hmong
Italian
Japanese
Korean
Polish
Portuguese
Russian
Tagalog
Vietnamese
____________________________________)
*A17. Which of the following statements BEST
describes this facility’s smoking policy for
clients?
MARK ONE ONLY
Not permitted to smoke anywhere outside or
within any building
2 Permitted in designated outdoor area(s)
3 Permitted anywhere outside
4 Permitted in designated indoor area(s)
5 Permitted anywhere inside
6 Permitted anywhere without restriction
1
*A18. Does this facility use a sliding fee scale?
SKIP TO A16b (TOP OF NEXT COLUMN)
A16a2. Do staff at this facility provide mental health
treatment services in any other languages?
1
Yes
SKIP TO A16b (TOP OF NEXT COLUMN)
0
No
SKIP TO A17 (NEXT COLUMN)
• Not applicable to Veterans Administration
facilities.
1 Yes
0 No
SKIP TO A19 (TOP OF NEXT PAGE)
A18a. Do you want the availability of a sliding fee scale
published in SAMHSA’s online Behavioral Health
Treatment Services Locator?
• Not applicable to Veterans Administration
facilities.
• The Locator will explain that sliding fee scales
are based on income and other factors.
1 Yes
0
4
No
*A19. Does this facility offer treatment at no charge to
clients who cannot afford to pay?
• Not applicable to Veterans Administration
facilities.
1 Yes
0
No
A21. 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.
SKIP TO A20 (BELOW)
MARK “YES” OR “NO” FOR EACH
A19a. Do you want the availability of treatment at no
charge for eligible clients published in
SAMHSA’s online Behavioral Health Treatment
Services Locator?
• Not applicable to Veterans Administration
facilities.
• The Locator will inform potential clients to call the
facility for information on eligibility.
1 Yes
0
No
*A20. Which of the following types of client payments,
insurance, or funding are accepted by this
facility for mental health treatment services?
MARK “YES,” “NO” OR “DON’T KNOW” FOR EACH
YES
NO
DON’T
KNOW
YES
NO
1. State mental health authority .......................... 1
0
2. State substance abuse agency ....................... 1
0
3. State department of health.............................. 1
0
Children’s Services ......................................... 1
0
5. Hospital licensing authority ............................. 1
0
6. The Joint Commission (JC)............................. 1
0
Rehabilitation Facilities (CARF) ...................... 1
0
8. Council on Accreditation (COA) ...................... 1
0
9. Centers for Medicare and Medicaid
Services (CMS).................................................... 1
0
0
4. State or local Department of Family and
7. Commission on Accreditation of
10. Other national organization, or federal,
1. Cash or self-payment ...................... 1
0
d
2. Private health insurance .................. 1
0
d
3. Medicare ........................................ 1
0
d
4. Medicaid .......................................... 1
0
d
0
d
0
d
INTAKE TELEPHONE NUMBER(S):
0
d
1. (____) ______ - ___________ ext.______
justice agency funds ........................ 1
0
d
9. State education agency funds ......... 1
0
d
state, or local agency (Specify:....................... 1
)
5. State-financed health insurance
plan other than Medicaid ................. 1
6. State mental health agency
(or equivalent) funds ........................ 1
*A22. What telephone number(s) should a potential
client call to schedule an intake appointment?
7. State welfare or child and family
services agency funds ..................... 1
8. State corrections or juvenile
10. Other state government funds ......... 1
0
d
11. County or local government funds ... 1
0
d
12. Community Service Block Grants .... 1
0
d
0
d
0
d
2. (____) ______ - ___________ ext.______
13. Community Mental Health Block
Grants .............................................. 1
14. Federal military insurance (such
as TRICARE) ................................... 1
15. U.S. Department of Veterans
Affairs funds ..................................... 1
0
d
16. IHS/Tribal/Urban (ITU) funds ........... 1
0
d
17. Other (Specify: ................................. 1
0
d
_____________________________)
5
SECTION C: GENERAL INFORMATION
C3a.
What is the NPI number for this facility?
• If the facility has more than one NPI number,
please provide only the primary number.
C1.
If eligible, does this facility want to be listed in
SAMHSA’s online Behavioral Health Treatment
Services Locator?
• The Locator can be found at:
https://findtreatment.samhsa.gov
C1a.
1
Yes
0
No
SKIP TO C2 (BELOW)
NPI
(NPI is a 10-digit numeric ID)
C4.
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.
To increase public awareness of behavioral
health services, SAMHSA may be sharing facility
contact information with large commercially
available Internet search engines, such as
Google, Bing, Yahoo!, etc. Do you want your
facility information shared on these Internet
search engines?
MARK ONE ONLY
•
Title:
Information to be shared would be: facility name,
location address, telephone number, and website
address.
1
Yes
0
No
1
Ms.
5
Other (Specify:
2
Mrs.
1
Yes
0
No
SKIP TO C3 (BELOW)
*C2a. What is this facility’s website address?
• Please enter the address exactly as it should be
entered in order to access your site.
• Do not enter http:// (for example, enter
www.yourfacility.com)
Website: _________________________________
C3.
6
Does this facility have a National Provider
Identifier (NPI) number?
• Do not include the NPI numbers of individual
practitioners and of groups of practitioners.
1
Yes
0
No
GO TO C3a (TOP OF NEXT COLUMN)
SKIP TO C4 (NEXT COLUMN)
4
Dr.
Phone Number: (_____) _______ - _______ Ext.
Fax Number:
Does this facility have a website or web page
with information about the facility’s mental
health treatment program(s)?
Mr.
Name:
(_____) _______ - _______
Email Address:
C2.
3
Facility Email Address:
)
ANY ADDITIONAL COMMENTS
Thank you for your participation. Please return this questionnaire in the envelope provided.
If you no longer have the envelope, please mail this questionnaire to:
MATHEMATICA POLICY RESEARCH
ATTN: RECEIPT CONTROL - Project 06667_1
P.O. Box 2393
Princeton, NJ 08543-2393
PLEDGE TO RESPONDENTS: The information you provide will be protected to the fullest extent allowable under Section 501(n) of the Public Health
Service Act (42 USC 290aa(n)). 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 may be published in SAMHSA’s online Behavioral Health Treatment
Services Locator, the National Directory of Mental Health Treatment Facilities, and other publically 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 0930-0119. Public reporting burden for this collection of information is
estimated to average 40 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room
15E57-B, Rockville, Maryland 20857.
7
| File Type | application/pdf |
| File Title | 2016 N-MHSS Questionnaire MINI (Non Variable) (5-2-16) |
| Author | RMcInerney |
| File Modified | 2016-05-02 |
| File Created | 2016-05-02 |