N-SSATS 2016 quest N-SSATS 2016 questionnaire - B

Attachment B2- N-SSATS 2016 questionnaire (Version B)
U.S. Department of Health and Human Services

OMB No. xxxx-xxxx
APPROVAL EXPIRES: xx/xx/20xx
See OMB burden statement on last page

National Survey of
Substance Abuse Treatment Services
(N-SSATS)
March 31, 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

Would you prefer to complete this questionnaire online? See the pink flyer enclosed in your packet
for the Internet address and your unique user ID and password. You can log on and off the 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 more information, call the N-SSATS helpline at 1-888-324-8337.

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.



If the questionnaire has not been completed online, return the completed questionnaire in the
envelope provided. Please keep a copy for your records.



For additional information about this survey and definitions of some of the terms used, please visit
our website at https://info.nssats.com.



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

MATHEMATICA POLICY RESEARCH
1-888-324-8337
NSSATSWeb@mathematica-mpr.com

IMPORTANT INFORMATION
* Asterisked questions. Information from asterisked (*) questions may be published in SAMHSA’s online
Behavioral Health Treatment Services Locator (found at https://findtreatment.samhsa.gov) and in
SAMHSA’s National Directory of Drug and Alcohol Abuse Treatment Programs, unless you designate
otherwise in question 29, page 11, of this questionnaire.
Mapping feature in online Locator. Complete and accurate name and address information is needed for
the online Locator so it can correctly map the facility location.
Eligibility for online Locator and Directory. Only facilities designated as eligible by their state substance
abuse office will be listed in the online Locator and Directory. Your state N-SSATS representative can tell
you if your facility is eligible to be listed in the online Locator and Directory. For the name and telephone
number of your state representative, call the N-SSATS helpline at 1-888-324-8337.

PREPARED BY MATHEMATICA POLICY RESEARCH

*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?

4.

Is this facility a jail, prison, or other organization
that provides treatment exclusively for
incarcerated persons or juvenile detainees?
1 
Yes
SKIP TO Q.36 (PAGE 12)
0 
No

5.

Is this facility a solo practice, meaning, an office
with only one independent practitioner or
counselor?
1
Yes
0
No

*6.

What is the primary focus of 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



0



0



3. Substance abuse treatment

(services that focus on initiating and
maintaining an individual’s recovery
from substance abuse and on averting
relapse) ............................................... 1 
4. Any other substance abuse

services ............................................. 1 

MARK ONE ONLY

1a.

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)?

1
2
3

4
5

 Substance abuse treatment services
 Mental health services
 Mix of mental health and substance abuse
treatment services (neither is primary)
 General health care
 Other (Specify: _______________________ )

MARK ALL THAT APPLY


2
3
1

Is this facility operated by . . .
MARK ONE ONLY
1
2
3

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

2.

*2a.

*7.

Substance abuse clients
Clients other than substance abuse clients
No clients are offered mental health
treatment services

1



Yes

0



No

4

5

SKIP TO Q.3 (BELOW)

6

A private for-profit organization
A private non-profit organization
State government
Local, county, or community
government
 Tribal government
 Federal Government

SKIP TO Q.8
(BELOW)

Does this facility detoxify clients from . . .
MARK “YES” OR “NO” FOR EACH

YES

*7a.

Which Federal Government agency?
MARK ONE ONLY

NO

1

1. Alcohol ................................................... 1 

0



2

2. Benzodiazepines ................................... 1 

0



3

3. Cocaine ................................................. 1 

0



4

4. Methamphetamines ............................... 1 

0



5. Opioids .................................................. 1 

0



) 1

0



6. Other (Specify:

*2b. Does this facility routinely use medications during
detoxification?
1
0




Yes
No

Did you answer “yes” to substance abuse
treatment in option 3 of question 1?
1
0

 Yes
 No

*8a.



GO TO Q.4 (NEXT COLUMN)

Department of Veterans Affairs
Department of Defense
Indian Health Service
Other (Specify: _______________________ )

No

SKIP TO Q.9 (NEXT PAGE)

What type of hospital?
MARK ONE ONLY



3
1

SKIP TO Q.4 (NEXT COLUMN)






*8. Is this facility a hospital or located in or operated
by a hospital?
1
Yes
0

3.






2

General hospital (including VA hospital)
Psychiatric hospital
Other specialty hospital, for example,
alcoholism, maternity, etc.
(Specify: _________________________ )

SKIP TO Q.28 (PAGE 11)
1

*9.

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

24

25

1. (______) ________ - ____________ ext._____
2. (______) ________ - ____________ ext._____

26
27

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

28
29

MARK ALL THAT APPLY
1

 Screening for substance abuse

2

 Screening for mental health disorders

3

4

5
6

7

8

 Comprehensive substance abuse assessment
or diagnosis

31

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

32

 Screening for tobacco use

35

 Outreach to persons in the community who
may need treatment

36

 Interim services for clients when immediate
admission is not possible
 We do not offer any of these assessment
and pre-treatment services

Testing (Include tests performed at this location,
even if specimen is sent to an outside source for
chemical analysis.)
9

 Breathalyzer or other blood alcohol testing

10

 Drug or alcohol urine screening

11

 Screening for Hepatitis B

12

 Screening for Hepatitis C

13

 HIV testing

14

 STD testing

15

 TB screening

16

 We do not offer any of these testing services

Transitional Services
18

 Discharge planning
 Aftercare/continuing care

19

 We do not offer any of these transitional services

17

30

Ancillary Services
20  Case management services
21  Social skills development
22  Mentoring/peer support
23  Child care for clients’ children

33
34

37

38
39

 Assistance with obtaining social services
(for example, Medicaid, WIC, SSI, SSDI)
 Employment counseling or training
for clients
 Assistance in locating housing for clients
 Domestic violence—family or partner
violence services (physical, sexual,
and emotional abuse)
 Early intervention for HIV
 HIV or AIDS education, counseling,
or support
 Hepatitis education, counseling,
or support
 Health education other than HIV/AIDS
or hepatitis
 Substance abuse education
 Transportation assistance to treatment
 Mental health services
 Acupuncture
 Residential beds for clients’ children
 Self-help groups (for example, AA, NA,
SMART Recovery)
 Smoking/tobacco cessation counseling
 We do not offer any of these ancillary
services

Other Services
40  Treatment for gambling disorder
41  Treatment for Internet use disorder
42  Treatment for other addiction disorder
(non-substance abuse)
43  We do not offer any of these other services
Pharmacotherapies
44  Disulfiram (Antabuse®)
45  Naltrexone (oral)
46  Vivitrol® (injectable Naltrexone)
47  Acamprosate (Campral®)
48  Nicotine replacement
49  Non-nicotine smoking/tobacco cessation
medications (for example, Bupropion,
Varenicline)
50  Medications for psychiatric disorders
51  Methadone
52  Buprenorphine with naloxone (Suboxone®)
53  Buprenorphine without naloxone
54  We do not offer any of these pharmacotherapy
services

2

*11.

How does this facility treat opioid (narcotic) addiction?
MARK ALL THAT APPLY
1
2

3

4

5

6

 This facility does not treat opioid addiction.
 This facility uses methadone or buprenorphine for pain management, emergency cases, or
research purposes. It is NOT a federally-certified OTP.
 This facility is “drug free.” It does not use medications to treat opioid addiction or accept
clients using medication to treat opioid addiction.

SKIP TO
Q.12 (BELOW)

 This facility accepts clients who are on methadone, buprenorphine and/or naltrexone
(Vivitrol®) maintenance or treatment, but these medications originate from or are
prescribed by another entity. (The medications may or may not be
stored/delivered/monitored onsite.)
 This facility prescribes and/or administers buprenorphine and/or naltrexone (Vivitrol®). This facility
is NOT a federally-certified OTP. Buprenorphine use is authorized through a Data 2000 waivered
physician.
 This facility administers and/or dispenses methadone, buprenorphine and/or naltrexone (Vivitrol®)
as a federally-certified Opioid Treatment Program (OTP). A Data 2000 waivered physician may or
may not also be onsite. (While most OTPs use methadone, some only use buprenorphine.)

*11a. Are ALL of the substance abuse clients at this facility currently receiving methadone, buprenorphine, or
naltrexone (Vivitrol®)?
1

 Yes

0

 No

*11b. Which of the following medication services does this program provide?
MARK ALL THAT APPLY

*12.

1

 Maintenance services with methadone or buprenorphine

2

 Maintenance services with medically-supervised withdrawal after a pre-determined time

3

 Detoxification services with methadone or buprenorphine

4

 Relapse prevention with naltrexone (Vivitrol®)

For each type of counseling listed below, please indicate approximately what percent of the substance abuse
clients at this facility receive that type of counseling as part of their substance abuse treatment program.
MARK ONE BOX FOR EACH
TYPE OF COUNSELING
TYPE OF COUNSELING

NOT OFFERED

RECEIVED BY 25% OR
LESS OF CLIENTS

RECEIVED BY 26% TO
50% OF CLIENTS

RECEIVED BY 51% TO
75% OF CLIENTS

RECEIVED BY MORE
THAN 75% OF CLIENTS

1. Individual counseling

1



2



3



4



5



2. Group counseling

1



2



3



4



5



3. Family counseling

1



2



3



4



5



4. Marital/couples counseling

1



2



3



4



5



3

*13.

For each type of clinical/therapeutic approach listed below, please mark the box that best describes how
often that approach is used at this facility.
 For definitions of these approaches, go to: https://info.nssats.com
MARK ONE FREQUENCY FOR EACH APPROACH

CLINICAL/THERAPEUTIC APPROACHES

NEVER

RARELY

SOMETIMES

ALWAYS
OR OFTEN

NOT FAMILIAR
WITH THIS
APPROACH

1. Substance abuse counseling

1



2



3



4



5



2. 12-step facilitation

1



2



3



4



5



3. Brief intervention

1



2



3



4



5



4. Cognitive-behavioral therapy

1



2



3



4



5



5. Dialectical behavior therapy

1



2



3



4



5



6. Contingency management/motivational incentives

1



2



3



4



5



7. Motivational interviewing

1



2



3



4



5



8. Trauma-related counseling

1



2



3



4



5



9. Anger management

1



2



3



4



5



10. Matrix Model

1



2



3



4



5



11. Community reinforcement plus vouchers

1



2



3



4



5



12. Rational emotive behavioral therapy (REBT)

1



2



3



4



5



13. Relapse prevention

1



2



3



4



5



14. Computerized substance abuse
treatment/telemedicine (including Internet, Web,
mobile, and desktop programs)

1



2



3



4



5



15. Other treatment approach (specify:

1



2



3



4



________________________________________________________ )

*14.

Does this facility, at this location, offer a specially designed program or group intended exclusively for
DUI/DWI or other drunk driver offenders?
1

 Yes

0

 No

SKIP TO Q.15 (NEXT PAGE)

*14a. Does this facility serve only DUI/DWI clients?
1

 Yes

0

 No

4

*15.

Does this facility provide substance abuse
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)?


*16.

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

1

 Yes

0

 No

 Yes

0

 No

1

 Hopi

2

 Lakota

3

 Navajo

4

 Ojibwa

5

 Yupik

SKIP TO Q.17 (NEXT PAGE)

 Staff counselor who speaks a language other
than English
 On-call interpreter (in person or by phone)
brought in when needed
SKIP TO Q.17

Other Languages:
7

 Arabic

8

 Any Chinese language

9

 Creole

10

 Farsi

11

 French

12

 German

13

 Greek

14

 Hebrew

15

 Hindi

16

 Hmong

17

 Italian

18

 Japanese

19

 Korean

20

 Polish

21

 Portuguese

22

 Russian

23

 Tagalog

24

 Vietnamese

25

 Any other language

(NEXT PAGE)
3

 BOTH staff counselor and on-call interpreter

*16a1. Do staff counselors provide substance abuse
treatment in Spanish at this facility?
1

 Yes

0

 No

 Other American Indian or
Alaska Native language
(Specify:_______________________________)

MARK ONE ONLY

2

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

MARK ALL THAT APPLY

6

16a. At this facility, who provides substance abuse
treatment services in a language other than
English?

1



American Indian or Alaska Native:

Does this facility provide substance abuse
treatment services in a language other than
English at this location?
1

*16b. In what other languages do staff counselors
provide substance abuse treatment at this
facility?

SKIP TO Q.17b (NEXT COLUMN)

16a2. Do staff counselors at this facility provide
substance abuse treatment in any other
languages?
1

 Yes

GO TO Q.16b (NEXT COLUMN)

0

 No

SKIP TO Q.17 (NEXT PAGE)

(Specify:______________________________)

5

*17.

Individuals seeking substance abuse treatment can vary by age, gender or other characteristics. Which
categories of individuals listed below are served by this facility, at this location?
MARK “YES” OR “NO” FOR
EACH CATEGORY

TYPE OF CLIENT

1. Female

SERVED BY THIS FACILITY

IF SERVED, WHAT IS
THE LOWEST AGE SERVED

IF SERVED, WHAT IS
THE HIGHEST AGE SERVED

1

0

No minimum
age

| | |
YEARS

0

No

| | |
YEARS

No maximum
age

0

No minimum
age

| | |
YEARS

0

No

| | |
YEARS

No maximum
age

1

2. Male

Yes

Yes

0

0

*17a. 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 abuse treatment program or group specifically tailored for clients in
that category? If this facility treats clients in any of these categories but does not have a specifically tailored
program or group for them, do not mark the box for that category.
MARK ALL THAT APPLY
1

 Adolescents

2

 Young adults

3

 Adult women

4

 Pregnant/postpartum women

5

 Adult men

6

 Seniors or older adults

7

 Lesbian, gay, bisexual, transgender (LGBT) clients

8

 Veterans

9

 Active duty military

10

 Members of military families

11

 Criminal justice clients (other than DUI/DWI)

12

 Clients with co-occurring mental and substance abuse disorders

13

 Clients with HIV or AIDS

14

 Clients who have experienced sexual abuse

15

 Clients who have experienced intimate partner violence, domestic violence

16

 Clients who have experienced trauma

17

 Specifically tailored programs or groups for any other types of clients
(Specify: ______________________________________________)

18

6

 No specifically tailored programs or groups are offered

*18.

Does this facility offer HOSPITAL INPATIENT
substance abuse services at this location, that is,
the location listed on the front cover?
1

 Yes

0

 No

*19a. Which of the following RESIDENTIAL services are
offered at this facility?
MARK “YES” OR “NO” FOR EACH

YES

SKIP TO Q.19 BELOW
1.

Residential detoxification .................. 1 
(Similar to ASAM Level III.2-D,
clinically managed residential
detoxification or social detoxification)

2.

Residential short-term treatment ...... 1 
(Similar to ASAM Level III.5, clinically
managed high-intensity residential
treatment, typically 30 days or less)

3.

Residential long-term treatment........ 1 
(Similar to ASAM Levels III.3 and
III.1, clinically managed medium- or
low-intensity residential treatment,
typically more than 30 days)

*18a. Which of the following HOSPITAL INPATIENT
services are offered at this facility?

NO
0



0



0



MARK “YES” OR “NO” FOR EACH

YES
Hospital inpatient detoxification ........ 1 
(Similar to ASAM Levels IV and III.7,
medically managed or monitored
intensive inpatient treatment)

1.

Hospital inpatient treatment .............. 1 
(Similar to ASAM Level III.5,
clinically managed high-intensity
residential treatment, typically
30 days or less)

2.

NO
0

0





NOTE: ASAM is the American Society of Addiction Medicine.
For more information on ASAM please go to
https://info.nssats.com.

19b. On March 31, 2016, how many clients received
RESIDENTIAL (non-hospital) substance abuse
services at this facility?

18b. On March 31, 2016, how many patients received
HOSPITAL INPATIENT substance abuse services
at this facility?


DO NOT count family members, friends, or other
non-treatment patients.



IF NONE, ENTER “0”
__________ HOSPITAL INPATIENTS



*19.

If you cannot report the number of hospital
inpatients for this facility alone, please check
here.



DO NOT count family members, friends, or other
non-treatment clients.



IF NONE, ENTER “0”
__________ RESIDENTIAL (NON-HOSPITAL)



*20.

If you cannot report the number of residential
clients for this facility alone, please check
here.

Does this facility offer OUTPATIENT substance
abuse services at this location, that is, the
location listed on the front cover?
1

 Yes

GO TO Q.20a (NEXT PAGE)

0

 No

SKIP TO Q.21 (NEXT PAGE)

Does this facility offer RESIDENTIAL
(non-hospital) substance abuse services at this
location, that is, the location listed on the front
cover?
1

 Yes

GO TO Q.19a (NEXT COLUMN)

0

 No

SKIP TO Q.20 (NEXT COLUMN)

7

*20a. Which of the following OUTPATIENT services are offered at this facility?
MARK “YES” OR “NO” FOR EACH

YES
1. Outpatient detoxification ............................................................................................................... 1 

NO
0



2. Outpatient methadone/ buprenorphine maintenance or Vivitrol® treatment ................................. 1 

0



3. Outpatient day treatment or partial hospitalization ....................................................................... 1 

0



0



0



(Similar to ASAM Levels I-D and II-D, ambulatory detoxification)

(Similar to ASAM Level II.5, 20 or more hours per week)
4. Intensive outpatient treatment ...................................................................................................... 1 

(Similar to ASAM Level II.1, 9 or more hours per week)
5. Regular outpatient treatment ........................................................................................................ 1 

(Similar to ASAM Level I, outpatient treatment, non-intensive)

20b. How many clients received OUTPATIENT substance abuse services at this facility during March 2016?



•

ONLY INCLUDE clients who received treatment in March AND were still enrolled in treatment on March 31, 2016.

•

DO NOT count family members, friends, or other non-treatment clients.



IF NONE, ENTER “0”
__________ OUTPATIENTS



If you cannot report the number of outpatients for this facility alone, please check here.

__________ Please record the total number of clients you indicated in questions 18b, 19b, and 20b.

21.

How many of the total number of clients listed in the box above received:


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



IF NONE, ENTER “0”



__________

Methadone dispensed at this facility

__________

Buprenorphine dispensed or prescribed at this facility

__________

Vivitrol® (injectable Naltrexone) administered at this facility

If you cannot report these numbers for this facility alone, please check here.

8

22.

This question concerns all paid staff providing patient services at this facility during the week of March 27 –
April 2, 2016.
Column A

For each staff category that is in a paid status, please record total number of people employed at this
facility. Make sure each staff member is counted only once, regardless of their full- or part-time status. (If
your facility does not employ staff in this category please record 0.)

Column B

Please record the total number of hours worked for this category of staff. For example, if this facility has
2 paid physicians where one is full-time (40 hours) and the other is part-time (20 hours), you should
report 60 hours in Column B.

Column C

Please record the total number of paid staff in this category, indicated in Column A, who are certified in
addiction treatment.

Full- and Part-time Paid Staff
COLUMN A
TOTAL NUMBER EMPLOYED
AT THIS FACILITY
STAFF

COLUMN B
TOTAL NUMBER OF HOURS
WORKED IN THE WEEK OF
MARCH 27 – APRIL 2, 2016

COLUMN C
NUMBER OF STAFF THAT
ARE ADDICTION
CERTIFIED

MEDICAL STAFF
1. Physician (MD, DO, Psychiatrist, etc.)

|

|

|

|

|

|

|

|

|

|

|

|

2. Pharmacist

|

|

|

|

|

|

|

|

|

|

|

|

3. Registered Nurse (RN)

|

|

|

|

|

|

|

|

|

|

|

|

4. Licensed Practical Nurse (LPN)

|

|

|

|

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5. Mid-level medical personnel (Nurse Practitioner,
PA, APRN, etc.)

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6. Doctoral level counselor (PhD Psychologist, etc.)

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7. Masters level counselor (MSW, MS, MA
Psychologist, etc.)

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8. Bachelors degreed counselor (BA, BS)

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9. Associate degree or non-degreed counselor

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10. Pharmacy assistant

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11. Peer support staff

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12. Care manager or patient navigator

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13. Other recovery support worker

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14. Administrative staff

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15. Other clinical staff (specify:
_____________________________________ )

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COUNSELING STAFF

SUPPORT STAFF

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23.

This question concerns all non-paid staff providing patient services at this facility during the week of
March 27 – April 2, 2016.
Column A

– For each staff category that is in a non-paid status, please record total number of people at this facility.

Column B

Please record the total number of hours worked for this category of staff. For example, if this facility has
3 non-paid peer support staff where each works 10 hours, you should report 30 hours in Column B.

Column C

Please record the total number of staff in this category, indicated in Column C, who are certified in
addiction treatment.

Full- and Part-time Non-Paid Staff
COLUMN A
TOTAL NUMBER EMPLOYED
AT THIS FACILITY
STAFF

COLUMN B
TOTAL NUMBER OF HOURS
WORKED IN THE WEEK OF
MARCH 27 – APRIL 2, 2016

COLUMN C
NUMBER OF STAFF THAT
ARE ADDICTION
CERTIFIED

MEDICAL STAFF
1.

Doctoral level medical staff (Physician (MD, DO,
Psychiatrist, Pharmacist etc.)

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Nursing staff (RN, LPN, PA, APRN, Nurse
practitioner, etc.)

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Post Graduate Counselors (PhD Psychologist,
MSW, MS, MA Psychologist, etc.)

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4.

Bachelors degreed counselor (BA, BS)

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5.

Associate degree or non-degreed Counselor

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2.

COUNSELING STAFF
3.

SUPPORT STAFF
6.

Pharmacy assistant

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7.

Care manager or patient navigator

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8.

Peer support staff

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9.

Other recovery support worker

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10. Administrative staff

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11. Other (specify:
____________________________________ )

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*24. Does this facility use a sliding fee scale?
1

 Yes

0

 No

SKIP TO Q.25 (NEXT PAGE)

24a. Do you want the availability of a sliding fee scale published in SAMHSA’s online Locator and Directory?
 The online Locator and Directory will explain that sliding fee scales are based on income and other factors.
1

 Yes

0

 No

10

*25.

Does this facility offer treatment at no charge to
clients who cannot afford to pay?
1 
Yes
0 
No
SKIP TO Q.26 (BELOW)

25a. Do you want the availability of free care for
eligible clients published in SAMHSA’s online
Locator and Directory?
 The online Locator and Directory will explain that
potential clients should call the facility for
information on eligibility.
1 
Yes
0 
No
*26. 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 are included in Q.27.
1

 Yes

0

 No

d

 Don’t Know

*28. Does this facility operate transitional housing or a
halfway house for substance abuse clients at this
location, that is, the location listed on the front
cover?
1

 Yes

0

 No

*29. Which of the following statements BEST describes
this facility’s smoking policy for clients?
MARK ONE ONLY
1



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

*30. Is this facility or program licensed, certified, or
accredited to provide substance abuse services
by any of the following organizations?

*27. 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
YES

1. No payment accepted .................. 1 

NO
0



3. Medicare ....................................... 1 
4. Medicaid ....................................... 1 

0

0

0





d



d

d

d





5. State-financed health insurance

plan other than Medicaid .............. 1 

0

6. Federal military insurance ............ 1 

0




d

d




(e.g., TRICARE)
7. Private health insurance ............... 1 
8. Access To Recovery .................... 1 

0

0




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

DON’T
KNOW

(free treatment for ALL clients)
2. Cash or self-payment ................... 1 

 Do not include personal-level credentials or general
business licenses such as a food service license.

d

d




(ATR vouchers)

YES

0



d



10. Other ............................................. 1 

0



d



0



d



2. State mental health department ..... 1 

0



d



3. State department of health ............. 1 

0



d



4. Hospital licensing authority ............ 1 

0



d



5. The Joint Commission .................... 1 

0



d



0



d



Quality Assurance (NCQA) ............ 1 

0



d



8. Council on Accreditation (COA) ..... 1 

0



d



0



d



0



d



6. Commission on Accreditation

of Rehabilitation Facilities (CARF)..1 
7. National Committee for

9. Healthcare Facilities

10. Other national organization

or federal, state, or local agency .... 1 
(Specify:

(Specify:

DON’T
KNOW

1. State substance abuse agency ...... 1 

Accreditation Program (HFAP)....... 1 

9. IHS/Tribal/Urban (ITU funds)........ 1 

NO

)

)
11

*31. Does this facility have a website or web page with
information about the facility’s substance abuse
treatment programs?
1

 Yes

0

 No

34.

SKIP TO Q.32 (BELOW)

*31a. If eligible, the website address for this facility will
appear in the Directory and online Locator. Please
provide the address exactly as it should be
entered in order to reach your site.

35.

 Yes

0

 No

 Yes

0

 No

SKIP TO Q.36 (BELOW)

What is the name, address, and phone number of
the facility that is the parent, or master site, of the
organization?

Address:

If eligible, does this facility want to be listed in the
Directory and the online Locator? (See inside front
cover for eligibility information.)
1

1

Name:

Web Address:

32.

Is this facility part of an organization with multiple
facilities or sites that provide substance abuse
treatment?

Phone Number: (_____) - ______ - __________
36.

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

33.

The Directory may be published on CD. If so,
would you like to receive a free copy of the CD?
(The Directory will also be available at
http://store.samhsa.gov in PDF format; search for
Directory.)
1



Yes

0



No

1

 Ms.

5

 Other (Specify:

2

 Mrs.

3

 Mr.

4

 Dr.
)

Name:
Title:
Phone Number: (_____) ____ Fax Number:

Ext.

(_____) ____ -

Email Address:
Facility Email Address:
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 Drug and Alcohol Abuse Treatment Programs, and other publically available listings. Responses to non-asterisked
questions will be published with no direct link to individual treatment facilities.

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
P.O. Box 2393
Princeton, NJ 08543-2393
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 xxxx-xxxx. 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, 1 Choke Cherry Road, Room 2-1057,
Rockville, Maryland 20857.

12