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pdfU.S. Department of Health and Human Services
OMB No. 0930-0106
APPROVAL EXPIRES: 12/31/2018
See OMB burden statement on last page
National Survey of
Substance Abuse Treatment Services
(N-SSATS)
March 31, 2017
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
PLEASE READ THIS ENTIRE PAGE BEFORE
COMPLETING THE QUESTIONNAIRE
Would you prefer to complete this questionnaire online? See the pink flyer enclosed in
your survey 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), in
SAMHSA’s National Directory of Drug and Alcohol Abuse Treatment Programs, and other publically
available listings, unless you designate otherwise in question 39, page 13 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.
3.
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?
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.40 (PAGE 13)
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
1. Intake, assessment, or referral ...... 1
2. Detoxification ................................... 1
NO
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
1a.
MARK ONE ONLY
0
0
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)?
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: ______________________ )
1
*7.
Is this facility operated by . . .
MARK ONE ONLY
3
4
A private for-profit organization
A private non-profit organization
State government
Local, county, or community
government
5
Tribal government
6
Federal Government
1
2
MARK ALL THAT APPLY
Substance abuse clients
2
Clients other than substance abuse clients
3
No clients are offered mental health treatment
services
1
2.
Did you answer “yes” to substance abuse
treatment in option 3 of question 1?
1
Yes
0
No
SKIP TO Q.35 (PAGE 12)
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)
*7a.
Which Federal Government agency?
MARK ONE ONLY
3
4
1
2
*2a.
Does this facility detoxify clients from . . .
MARK “YES” OR “NO” FOR EACH
1.
2.
3.
4.
5.
6.
*2b.
YES
Alcohol ............................................... 1
Benzodiazepines ............................... 1
Cocaine ............................................. 1
Methamphetamines ........................... 1
Opioids .............................................. 1
Other (Specify:_______________) .. 1
NO
0
0
0
0
0
0
Does this facility routinely use medications
during detoxification?
1
Yes
SKIP TO Q.4 (NEXT COLUMN)
0
No
SKIP TO
Q.8
(BELOW)
Department of Veterans Affairs
Department of Defense
Indian Health Service
Other (Specify: ______________________ )
8.
Is this facility affiliated with a religious
organization?
1
Yes
0
No
*9.
Is this facility a hospital or located in or operated
by a hospital?
1
Yes
GO TO Q.9a (TOP OF NEXT PAGE)
0
No
SKIP TO Q.10 (NEXT PAGE)
1
*9a.
What type of hospital?
MARK ONE ONLY
General hospital (including VA hospital)
Psychiatric hospital
3
Other specialty hospital, for example,
alcoholism, maternity, etc.
1
2
(Specify: ___________________________ )
*10. What telephone number(s) should a potential
client call to schedule an intake appointment?
1. (______) ________ - ____________ ext._____
2. (______) ________ - ____________ ext._____
*11. 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
1
2
3
4
5
6
7
8
Screening for substance abuse
Screening for mental health disorders
Comprehensive substance abuse assessment or
diagnosis
Comprehensive mental health assessment or
diagnosis (for example, psychological or
psychiatric evaluation and testing)
Screening for tobacco use
Outreach to persons in the community who may
need treatment
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
17 Discharge planning
18 Aftercare/continuing care
19 We do not offer any of these transitional services
Ancillary Services
20 Case management services
21
2
Social skills development
Mentoring/peer support
Child care for clients’ children
24 Assistance with obtaining social services
(for example, Medicaid, WIC, SSI, SSDI)
25 Employment counseling or training for
clients
26 Assistance in locating housing for clients
27 Domestic violence—family or partner
violence services (physical, sexual,
and emotional abuse)
28 Early intervention for HIV
29 HIV or AIDS education, counseling, or
support
30 Hepatitis education, counseling, or
support
31 Health education other than HIV/AIDS
or hepatitis
32 Substance abuse education
33 Transportation assistance to treatment
34 Mental health services
35 Acupuncture
36 Residential beds for clients’ children
37 Self-help groups (for example, AA, NA,
SMART Recovery)
38 Smoking/tobacco cessation counseling
39 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 Naltrexone (extended-release,
injectable, for example, Vivitrol®)
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
22
23
*12.
How does this facility treat opioid (narcotic) addiction?
MARK ALL THAT APPLY
*12a.
1
This facility does not treat opioid addiction.
2
This facility uses methadone or buprenorphine for pain management, emergency
cases, or research purposes. It is NOT a federally-certified OTP.
3
This facility treats opioid addiction, but it does not use methadone, buprenorphine,
and/or naltrexone to treat opioid addiction, nor does it accept clients using those
medications to treat opioid addiction.
4
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.)
5
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.
6
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.)
Are ALL of the substance abuse clients at this facility currently receiving methadone, buprenorphine, or
extended-release, injectable naltrexone (Vivitrol®)?
1
0
*12b.
SKIP TO
Q.13 (BELOW)
Yes
No
Which of the following medication services does this program provide?
MARK ALL THAT APPLY
2
3
4
1
*13.
Maintenance services with methadone or buprenorphine
Maintenance services with medically-supervised withdrawal after a pre-determined time
Detoxification services with methadone or buprenorphine
Relapse prevention with extended-release, injectable 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
*14. 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
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
________________________________________________________ )
15.
Are any of the following practices part of this facility’s standard operating procedures?
MARK ALL THAT APPLY
2
3
4
5
6
7
8
1
4
NOT FAMILIAR
WITH THIS
APPROACH
Required continuing education for staff
Periodic drug testing of clients
Regularly scheduled case review with a supervisor
Case review by an appointed quality review committee
Outcome follow-up after discharge
Periodic utilization review
Periodic client satisfaction surveys conducted by the facility
None of these practices are part of the standard operating procedures
*16.
Does this facility, at this location, offer a
specially designed program or group
intended exclusively for DUI/DWI or other
drunk driver offenders?
Yes
0
No
*18b.
In what other languages do staff counselors
provide substance abuse treatment at this
facility?
• Do not count languages provided only by on-call
interpreters.
1
SKIP TO Q.17 (BELOW)
MARK ALL THAT APPLY
American Indian or Alaska Native:
*16a.
Does this facility serve only DUI/DWI clients?
Yes
0
No
1
Hopi
2
Lakota
3
Navajo
4
Ojibwa
5
Yupik
6
Other American Indian or Alaska Native
language
1
*17.
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)?
• Mark “yes” if either a staff counselor or an on-call
interpreter provides this service.
1
Yes
0
No
*18.
Other Languages:
Does this facility provide substance abuse
treatment services in a language other than
English at this location?
Yes
0
No
1
18a.
SKIP TO Q.19 (NEXT PAGE)
At this facility, who provides substance
abuse treatment services in a language other
than English?
MARK ONE ONLY
Staff counselor who speaks a language other
than English
2
On-call interpreter (in person or by phone)
brought in when needed
SKIP TO Q.19
1
(TOP OF NEXT
PAGE)
3
BOTH staff counselor and on-call interpreter
*18a1. Do staff counselors provide substance
abuse treatment in Spanish at this facility?
Yes
0
No
(Specify: __________________________ )
1
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
SKIP TO Q.18b (NEXT COLUMN)
(Specify: __________________________ )
18a2.
Do staff counselors at this facility provide
substance abuse treatment in any other
languages?
1
Yes
GO TO Q.18b (TOP OF NEXT COLUMN)
0
No
SKIP TO Q.19 (TOP OF NEXT PAGE)
5
*19.
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?
• 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.
MARK “YES” OR “NO” FOR
EACH CATEGORY
TYPE OF CLIENT
IF SERVED, WHAT IS
THE LOWEST AGE SERVED
SERVED BY THIS FACILITY
1. Female
1
Yes
0
No
| | |
YEARS
0
No minimum age
| | |
YEARS
0
No maximum age
2. Male
1
Yes
0
No
| | |
YEARS
0
No minimum age
| | |
YEARS
0
No maximum age
*19a.
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
IF SERVED, WHAT IS
THE HIGHEST AGE SERVED
No specifically tailored programs or groups are offered
*20.
*20a.
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
*22.
Does this facility offer OUTPATIENT
substance abuse services at this location,
that is, the location listed on the front cover?
SKIP TO Q.21 (BELOW)
Which of the following HOSPITAL INPATIENT
services are offered at this facility?
*22a.
1
Yes
0
No
Which of the following OUTPATIENT
services are offered at this facility?
MARK “YES” OR “NO” FOR EACH
YES
1. Hospital inpatient detoxification ........ 1
MARK “YES” OR “NO” FOR EACH
NO
0
YES
(Similar to ASAM Levels IV-D and
III.7-D, medically managed or
monitored inpatient detoxification)
2. Hospital inpatient treatment .............. 1
0
*21a.
Does this facility offer RESIDENTIAL
(non-hospital) substance abuse services at
this location, that is, the location listed on
the front cover?
Yes
0
No
Outpatient detoxification ................... 1
(Similar to ASAM Levels I-D and II-D,
ambulatory detoxification)
2.
Outpatient methadone/
buprenorphine maintenance
or Vivitrol® treatment ......................... 1
Outpatient day treatment
or partial hospitalization .................... 1
(Similar to ASAM Level II.5, 20 or
more hours per week)
3.
NOTE: ASAM is the American Society of Addiction Medicine.
For more information on ASAM please go to
https://info.nssats.com.
1
1.
(Similar to ASAM Levels IV and III.7,
medically managed or monitored
intensive inpatient treatment)
*21.
*23.
Which of the following RESIDENTIAL
services are offered at this facility?
MARK “YES” OR “NO” FOR EACH
1. Residential detoxification .................. 1
23a.
NO
0
0
(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)
0
0
Intensive outpatient treatment .......... 1
(Similar to ASAM Level II.1, 9 or
more hours per week)
0
5.
Regular outpatient treatment ............ 1
(Similar to ASAM Level I, outpatient
treatment, non-intensive)
0
Does this facility use a sliding fee scale?
1
Yes
0
No
SKIP TO Q.24 (BELOW)
Do you want the availability of a sliding fee
scale published in SAMHSA’s online Locator
and Directory?
0
*24.
0
0
• The online Locator and Directory will explain that
sliding fee scales are based on income and other
factors.
1
Yes
(Similar to ASAM Level III.2-D,
clinically managed residential
detoxification or social detoxification)
2. Residential short-term treatment ...... 1
NO
4.
SKIP TO Q.22 (TOP OF NEXT COLUMN)
YES
SKIP TO Q.23 (BELOW)
No
Does this facility offer treatment at no charge
to clients who cannot afford to pay?
1
Yes
GO TO Q.24a (TOP OF NEXT PAGE)
0
No
SKIP TO Q.25 (NEXT PAGE)
7
24a.
*25.
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
• Do not include Medicare, Medicaid, or federal
military insurance. These forms of client payments
are included in Q.26.
*26.
Yes
0
No
d
Don’t Know
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
MARK ONE METHOD FOR EACH ACTIVITY
COMPUTER/
ELECTRONIC
ONLY
PAPER
ONLY
BOTH
ELECTRONIC
AND PAPER
NA
1. Intake
1
2
3
na
2. Scheduling
appointments
1
2
3
na
3. Assessment
1
2
3
na
4. Treatment plan
1
2
3
na
5. Client progress
monitoring
1
2
3
na
6. Discharge
1
2
3
na
7. Referrals
1
2
3
na
8. Issue/receive
lab results
1
2
3
na
9. Billing
1
2
3
na
10. Outcomes
management
1
2
3
na
1
2
3
na
treatment for ALL clients) ............ 1
0
d
11. Medication
prescribing/
dispensing
2. Cash or self-payment .................. 1
0
d
12. Health records
1
2
3
na
3. Medicare ..................................... 1
0
d
4. Medicaid ...................................... 1
0
d
0
d
13. Interoperability
with other
providers (such
as primary
care, mental
health
providers,
criminal justice,
etc.)
1
2
3
na
(e.g., TRICARE) .......................... 1
0
d
7. Private health insurance ............. 1
0
d
(ATR vouchers) ........................... 1
0
d
9. IHS/Tribal/Urban (ITU funds) ...... 1
0
d
10. Other ........................................... 1
0
d
1. No payment accepted (free
5. State-financed health insurance
plan other than Medicaid ............ 1
6. Federal military insurance
8. Access To Recovery
(Specify:
8
For each of the following activities, please indicate
if staff members routinely use computer or
electronic resources, paper only, or a combination
of both to accomplish their work.
WORK ACTIVITY
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?
1
27.
)
SECTION B:
REPORTING CLIENT COUNTS
28.
Questions 29 through 34 ask about the number of
clients in treatment. If possible, report clients for
this facility only. However, we realize that is not
always possible. Please indicate whether the
clients you report will be for . . .
MARK ONE ONLY
1
Only this facility
2
This facility plus others
3
Another facility will report this facility’s
client counts
SKIP TO Q.35 (PAGE 12)
SKIP TO Q.29 (TOP OF NEXT
PAGE)
HOSPITAL INPATIENT CLIENT COUNTS
29.
On March 31, 2017, did any patients receive
HOSPITAL INPATIENT substance abuse services
at this facility?
1 Yes
0 No
SKIP TO Q.30 (TOP OF NEXT PAGE)
29a. On March 31, 2017, 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)
28a. How many facilities will be included in your client
counts?
THIS FACILITY
2. Hospital inpatient treatment
_____________
(Similar to ASAM Levels IV
and III.7, medically managed or
monitored intensive inpatient treatment)
1
+ ADDITIONAL FACILITIES
HOSPITAL INPATIENT
TOTAL BOX
TOTAL FACILITIESα
α
For Section B, please include all of these
facilities in the client counts that you report
in questions 29 through 34.
NOTE: ASAM is the American Society of Addiction Medicine.
For more information on ASAM please go to https://info.nssats.com.
29b. How many of the patients from the HOSPITAL
INPATIENT TOTAL BOX were under the age of 18?
ENTER A NUMBER
(IF NONE, ENTER “0”)
28b. To avoid double-counting clients, we need to know
which facilities are included in your counts. How
will you report this information to us?
MARK ONE ONLY
1
2
By listing the names and location addresses of
these additional facilities in the “Additional
Facilities Included in Client Counts” section on
page 14 of this questionnaire or attaching a sheet
of paper to this questionnaire
Please call me for a list of the additional facilities
included in these counts
Number under age 18
29c.
_______________
How many of the patients from the HOSPITAL
INPATIENT TOTAL BOX received:
• Include patients who received these drugs for
detoxification or maintenance purposes.
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)
1.
2.
3.
Methadone dispensed
at this facility
_______________
Buprenorphine dispensed or
prescribed at this facility
_______________
®
Vivitrol administered
at this facility
_______________
29d. On March 31, 2017, how many hospital inpatient
beds were specifically designated for substance
abuse treatment?
ENTER A NUMBER
(IF NONE, ENTER “0”)
Number of beds
_______________
9
RESIDENTIAL (NON-HOSPITAL)
CLIENT COUNTS
30.
30d.
On March 31, 2017, how many residential beds
were specifically designated for substance abuse
treatment?
ENTER A NUMBER
(IF NONE, ENTER “0”)
On March 31, 2017, did any clients receive
RESIDENTIAL (non-hospital) substance abuse
services at this facility?
1 Yes
0 No
SKIP TO Q.31 (NEXT COLUMN)
Number of beds
_______________
OUTPATIENT CLIENT COUNTS
30a.
On March 31, 2017, 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
31.
31a.
During the month of March 2017, did any clients
receive OUTPATIENT substance abuse services
at this facility?
1
Yes
0
No
SKIP TO Q.32 (NEXT PAGE)
How many clients received each of the following
OUTPATIENT substance abuse services at this
facility during March 2017?
clients who received treatment
in March AND were
still enrolled in treatment on
ONLY INCLUDE
March 31, 2017.
• 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
2. Outpatient methadone/
30b.
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
30c.
_______________
How many of the clients from the RESIDENTIAL
TOTAL BOX received:
• Include clients who received these drugs for
detoxification or maintenance purposes.
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)
_________
(Similar to ASAM
Levels I-D and II-D,
ambulatory detoxification)
_________
buprenorphine maintenance
or Vivitrol® treatment
(Count methadone/buprenorphine/
Vivitrol® clients on this line only)
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)
1. Methadone dispensed
at this facility
_______________
2. Buprenorphine dispensed
or prescribed at this facility _______________
3. Vivitrol® administered
at this facility
10
_______________
5. Regular outpatient treatment
(Similar to ASAM Level I,
outpatient treatment,
non-intensive)
OUTPATIENT
TOTAL BOX
_________
31b.
How many of the clients from the OUTPATIENT
TOTAL BOX were under the age of 18?
32.
ENTER A NUMBER
(IF NONE, ENTER “0”)
Number under age 18
31c.
_______________
Enter the percent of clients on March 31, 2017,
who were in each of these three groups:
Clients in treatment for abuse of:
How many of the clients from the OUTPATIENT
TOTAL BOX received:
1. BOTH alcohol and substances
other than alcohol
• Include clients who received these drugs for
detoxification or maintenance purposes.
alcohol
31d.
33.
MARK ONE ONLY
1
Well over capacity (over 120%)
2
Somewhat over capacity (106 to 120%)
3
At or about capacity (95 to 105%)
4
Somewhat under capacity (80 to 94%)
5
Well under capacity (under 80%)
34.
100%
Approximately what percent of the substance
abuse treatment clients enrolled at this facility
on March 31, 2017, had a diagnosed co-occurring
mental and substance abuse disorder?
PERCENT OF CLIENTS
(IF NONE, ENTER “0”)
_______________
On average, during March 2017, were the
outpatient substance abuse treatment services
at this facility operating over, under, or at
capacity?
___________%
TOTAL
_______________
or prescribed at this facility _______________
3. Vivitrol® administered
at this facility
___________%
3. ONLY substances other than
1. Methadone dispensed
2. Buprenorphine dispensed
___________%
2. ONLY alcohol
ENTER A NUMBER FOR EACH
(IF NONE, ENTER “0”)
at this facility
This question asks you to categorize the
substance abuse treatment clients at this
facility into three groups: clients in treatment for
(1) abuse of both alcohol and substances other
than alcohol; (2) abuse only of alcohol; or
(3) abuse only of substances other than alcohol.
%
Using the most recent 12-month period for
which you have data, approximately how many
substance abuse 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
abuse treatment, even if substance abuse was
their secondary diagnosis.
NUMBER OF SUBSTANCE
ABUSE ADMISSIONS IN A
12-MONTH PERIOD
11
SECTION C:
GENERAL INFORMATION
*35.
*36.
*37.
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
Is this facility or program licensed, certified,
or accredited to provide substance abuse
services by any of the following
organizations?
• Do not include personal-level credentials or
general business licenses such as a food service
license.
MARK “YES,” “NO,” OR “DON’T KNOW” FOR EACH
YES
Which of the following statements BEST
describes this facility’s smoking policy for
clients?
NO
DON’T
KNOW
1. State substance abuse agency .... 1
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
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
6. Commission on Accreditation of
Rehabilitation Facilities (CARF) ... 1
7. National Committee for
9. Healthcare Facilities
Accreditation Program (HFAP) ..... 1
10. Other national organization
or federal, state, or local agency .. 1
(Specify:
*38.
*38a.
Does this facility have a website or web page
with information about the facility’s
substance abuse treatment programs?
1
Yes
0
No
SKIP TO Q.39 (TOP OF NEXT PAGE)
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.
Web Address:
12
)
39.
If eligible, does this facility want to be listed in the Directory and the online Locator? (See inside front cover for
eligibility information)
• The Directory will be available at http://www.samhsa.gov/data/substance-abuse-facilities-data-nssats
• The Locator can be found at: https://findtreatment.samhsa.gov
39a.
1
Yes
0
No
SKIP TO Q.40 (BELOW)
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?
• Information to be shared would be: facility name, location address, telephone number, and website address.
40.
1
Yes
0
No
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
1
Ms.
5
Other (Specify:
2
Mrs.
3
Mr.
4
Dr.
)
Name:
Title:
Phone Number: (_____) ______________ - ____________
Fax Number:
Ext. _____________
(_____) ______________ - ____________
Email Address:
Facility Email Address:
13
ADDITIONAL FACILITIES INCLUDED IN CLIENT COUNTS
Complete this section if you reported clients for this facility plus other facilities, as indicated in Question 29.
For each additional facility, please mark if that facility offers hospital inpatient, residential and/or outpatient
substance abuse services at that location.
FACILITY NAME:
FACILITY NAME:
ADDRESS:
ADDRESS:
CITY:
CITY:
STATE:
ZIP:
STATE:
PHONE:
PHONE:
FACILITY EMAIL
ADDRESS:
FACILITY EMAIL
ADDRESS:
HOSPITAL INPATIENT
RESIDENTIAL
OUTPATIENT
HOSPITAL INPATIENT
FACILITY NAME:
FACILITY NAME:
ADDRESS:
ADDRESS:
CITY:
CITY:
STATE:
ZIP:
PHONE:
FACILITY EMAIL
ADDRESS:
FACILITY EMAIL
ADDRESS:
RESIDENTIAL
OUTPATIENT
HOSPITAL INPATIENT
FACILITY NAME:
FACILITY NAME:
ADDRESS:
ADDRESS:
CITY:
CITY:
STATE:
ZIP:
PHONE:
FACILITY EMAIL
ADDRESS:
FACILITY EMAIL
ADDRESS:
RESIDENTIAL
OUTPATIENT
HOSPITAL INPATIENT
RESIDENTIAL
OUTPATIENT
ZIP:
RESIDENTIAL
If you require additional space, please continue on the next page.
14
OUTPATIENT
ZIP:
STATE:
PHONE:
HOSPITAL INPATIENT
RESIDENTIAL
STATE:
PHONE:
HOSPITAL INPATIENT
ZIP:
OUTPATIENT
ANY ADDITIONAL COMMENTS
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 nonasterisked 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 0930-0106. 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.
15
| File Type | application/pdf |
| File Title | N-SSATS 2017 Questionnaire Non_Variable (5-2-16) |
| Author | RMcInerney |
| File Modified | 2016-05-03 |
| File Created | 2016-05-02 |