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pdfOMB: 0930-0386
Expiration Date: XX/XX/XXXX
NATIONAL SUBSTANCE USE AND MENTAL HEALTH SERVICES SURVEY
(N-SUMHSS)
1. What type of treatment does this facility, at this location, provide?
o Primarily Substance use treatment services
o Primarily Mental health services
o Mix of mental health and substance use treatment services
o No treatment for either substance use or mental health is provided at this
location
1a. Do you also provide substance use treatment services?
Select “Yes” if this facility offers substance use treatment as a stand-alone service.
Select “No” if it only offers substance use treatment as part of mental health treatment services
for individual patients who need it.
o Yes
o No
2. Is this facility a jail, prison, or detention center that provides treatment exclusively for
incarcerated persons or juvenile detainees?
o Yes
o No
Pledge to Respondents: The information you provide will be protected to the fullest extent allowable under the Public Health
Service Act (42 USC 290aa(p)). This law permits the public release of identifiable information about an establishment only with
the consent of that establishment and limits the use of the information to the purposes for which it was supplied. With the explicit
consent of treatment facilities, information provided in response to survey questions marked with an asterisk may be published on
FindTreatment.gov, the National Directory of Drug and Alcohol Use Treatment Facilities, the National Directory of Mental Health
Treatment Facilities, and other publicly available listings. Responses to non-asterisked questions will be published with no direct
link to individual treatment facilities.
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0386. Public
reporting burden for this collection of information is estimated to average XX minutes per facility, per year, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 15E57-A,
Rockville, Maryland 20857.
1
MODULE A: SUBSTANCE USE TREATMENT FACILITIES
A1. Which of the following substance use treatment services are offered by this facility at this
location, that is, the location listed on the front cover?
MARK “YES” OR “NO” FOR EACH
Intake, assessment, or referral
o Yes
o No
Detoxification (medical withdrawal)
o Yes
o No
Substance use disorder treatment
(services that focus on initiating and maintaining
an individual’s recovery from substance use and
on averting relapse)
o Yes
o No
Treatment for co-occurring substance use plus
either serious mental illness (SMI) in adults
and/or serious emotional disturbance (SED) in
children
o Yes
o No
Any other substance use treatment services
(such as 12 step meeting facilitation, naloxone
prescriptions, etc.)
o Yes
o No
A1a. To which of the following clients does this facility, at this location, offer mental health
treatment services (interventions such as therapy or psychotropic medication that treat a
person’s mental health problem or condition, reduce symptoms, and improve behavioral
functioning and outcomes)?
MARK ALL THAT APPLY
Substance use treatment clients
Clients other than substance use treatment clients
No clients are offered mental health treatment services at this facility
2
*A2. Does this facility detoxify (medical withdrawal) clients from:
MARK ALL THAT APPLY
Alcohol
Benzodiazepines
Cocaine
Methamphetamines
Opioids
Other(s):(Specify________________)
*A2a. Does this facility routinely use medication during detoxification (medical withdrawal)?
o Yes
o No
A3. Is this facility a solo practice, that is, an office with only one independent practitioner or
counselor?
o Yes
o No
3
*A4. Does this facility offer HOSPITAL INPATIENT substance use treatment services at this
location, that is, the location listed on the front cover?
o Yes
o No
*A4a. Which of the following INPATIENT services are offered at this facility?
MARK “YES” OR “NO” FOR EACH
Inpatient detoxification (medical withdrawal)
(medically managed or monitored inpatient
detoxification)
Inpatient treatment (medically
managed or monitored intensive
inpatient treatment))
o Yes
o No
o Yes
o No
4
*A5. Does this facility offer RESIDENTIAL (non-hospital) substance use treatment services at this
location, that is, the location listed on the front cover?
o Yes
o No
*A5a. Which of the following RESIDENTIAL services are offered at this facility?
MARK “YES” OR “NO” FOR EACH
Residential detoxification (medical withdrawal)
(clinically managed residential detoxification or
social detoxification)
Residential short-term treatment (clinically
managed high-intensity residential treatment,
typically 30 days or less)
Residential long-term treatment (clinically
managed medium- or low-intensity residential
treatment)
o Yes
o No
o Yes
o No
o Yes
o No
5
*A6. Does this facility offer OUTPATIENT substance use treatment services at this location; that
is, the location listed on the front cover?
o Yes
o No
*A6a. Which of the following OUTPATIENT services are offered at this facility?
MARK “YES” OR “NO” FOR EACH
Outpatient detoxification (Ambulatory
detoxification)
o Yes
o No
Outpatient methadone/buprenorphine
maintenance or naltrexone treatment
o Yes
o No
Outpatient day treatment or partial
hospitalization (20 or more hours per week)
o Yes
o No
Intensive outpatient treatment (9 or more hours
per week)
o Yes
o No
Regular outpatient treatment (outpatient
treatment, non-intensive)
o Yes
o No
6
*A7. Which of the following services are offered by this facility at this location, that is, the location
listed on the front cover?
MARK ALL THAT APPLY
Assessment and Pre-Treatment Services
Screening for substance use
Screening for mental disorders
Comprehensive substance use assessment or diagnosis
Comprehensive mental health assessment or diagnosis (for example, psychological or
psychiatric evaluation and testing)
Complete medical history and physical exam performed by a healthcare practitioner
Screening for tobacco use
Outreach to persons in the community who may need treatment
Interim services for clients when immediate admission is not possible
Professional interventionist/educational consultant
None of the assessment and pre-treatment services above are offered at this facility
7
MARK ALL THAT APPLY
Testing (include tests performed at this location, even if specimen is sent to an outside source for
chemical analysis.)
Drug and alcohol oral fluid testing
Breathalyzer or other blood alcohol testing
Drug or alcohol urine screening
Testing for Hepatitis B (HBV)
Testing for Hepatitis C (HCV)
HIV testing
STD testing
TB screening
Testing for metabolic syndrome (weight, abdominal girth, BP, glucose, Hgb A1C, cholesterol,
triglycerides)
None of the testing services above are offered at this facility
8
Medical Services
Hepatitis A (HAV) vaccination
Hepatitis B (HBV) vaccination
None of the medical services above are offered at this facility
Transitional Services
Discharge planning
Aftercare/continuing care
Naloxone and overdose education
Outcome follow-up after discharge
None of the transitional services above are offered at this facility
9
Recovery Support Services
Mentoring/peer support
Self-help groups (for example, AA, NA, SMART Recovery)
Assistance in locating housing for clients
Employment counseling or training for clients
Assistance with obtaining social services (for example, Medicaid, WIC, SSI, SSDI)
Recovery coach
None of the recovery support services above are offered at this facility
10
Education and Counseling Services
HIV or AIDS education, counseling, or support
Hepatitis education, counseling, or support
Health education other than HIV/AIDS or Hepatitis
Substance use disorder education
Smoking/tobacco cessation counseling
Individual counseling
Group counseling
Family counseling
Marital/couples counseling
Vocational training or educational support (for example, high school coursework, GED
preparation, etc.)
None of the education and counseling services above are offered at this facility
11
Ancillary Services
Case management services
Integrated primary care services
Social skills development
Child care for clients’ children
Domestic violence services, including family or partner violence services, for physical, sexual,
or emotional abuse
Early intervention for HIV
Transportation assistance to treatment
Mental health services
Suicide prevention services
Acupuncture
Residential beds for clients’ children
None of the ancillary services above are offered at this facility
Other Services
Treatment for gambling disorder
Treatment for other addiction disorder (non-substance use disorder)
None of the other services above are offered at this facility
12
Pharmacotherapies
Disulfiram
Naltrexone (oral)
Naltrexone (extended-release, injectable)
Acamprosate
Nicotine replacement
Non-nicotine smoking/tobacco cessation medications (for example, bupropion, varenicline)
Medications for mental disorders
Methadone
Buprenorphine/naloxone
Buprenorphine without naloxone
Buprenorphine sub-dermal implant
Buprenorphine (extended-release, injectable)
Medications for HIV treatment (for example, antiretroviral medications such as tenofovir,
efavirenz, emtricitabine, atazanavir, and lamivudine)
Medications for pre-exposure prophylaxis (PrEp: for example, emtricitabine and tenofovir
disoproxil fumarate combination, and emtricitabine and tenofovir alafenamide combination)
Medications for Hepatitis C (HCV) treatment (for example, sofosbuvir, ledipasvir, interferon,
peginterferon, ribavirin)
Lofexidine
Clonidine
Medications for other medical conditions (Specify:______________)
None of the pharmacotherapy services above are offered at this facility
13
*A8. Facilities may treat a range of substance use disorders. The next series of questions focuses
only on how this facility treats opioid use disorder. How does this facility treat opioid use
disorder?
• Medication-assisted treatment (MAT) includes the use of methadone, buprenorphine
products and/or naltrexone for the treatment of opioid use disorder. For this question, MAT
refers to any or all of these medications unless specified otherwise.
MARK ALL THAT APPLY
This facility accepts clients using MAT, but the medications originate from or are prescribed by
another entity. (The medications may or may not be stored/delivered/monitored onsite.)
This facility prescribes naltrexone to treat opioid use disorder. Naltrexone use is authorized
through any medical staff with prescribing privileges.
This facility utilizes prescribers of buprenorphine to treat opioid use disorder. Buprenorphine
use is authorized through a DATA 2000 waivered physician, physician assistant, or nurse
practitioner.
This facility is a federally certified Opioid Treatment Program (OTP). (Most OTPs
administer/dispense methadone; some only use buprenorphine, some provide all FDAapproved medication treatments for opioid use disorder.)
This facility treats opioid use disorder, but it does not use medication-assisted treatment (MAT),
nor does it accept clients using MAT to treat opioid use disorder.
This facility uses methadone or buprenorphine for pain management, emergency cases, or
research purposes. It is NOT a federally certified Opioid Treatment Program (OTP).
This facility does not treat opioid use disorder
*A8a. For those clients using MAT for opioid use disorder, but whose medications originate from
or are prescribed by another entity, the clients obtain their prescriptions from
MARK ALL THAT APPLY
A prescribing entity in our network
A prescribing entity with which our facility has a business, contractual, or formal referral
relationship
A prescribing entity with which our facility has no formal relationship
14
*A8b. Does this facility serve only opioid use disorder clients?
o Yes
o No
*A8c. Which of the following medication services does this program provide for opioid use
disorder?
MARK ALL THAT APPLY
Maintenance services with methadone or buprenorphine
Maintenance services with medically supervised withdrawal (or taper) after a period of
stabilization
Detoxification (medical withdrawal) from opioids of abuse with methadone or buprenorphine
Detoxification (medical withdrawal) from opioids of abuse with lofexidine or clonidine
Relapse prevention with naltrexone
Other (for example, overdose risk reduction with naloxone, specify opioid use disorder service
and pharmacotherapy used:
______________________________________________________ )
None of the medication services for opioid use disorder above are offered at this facility
15
*A9. Facilities may treat a range of substance use disorders. The next series of questions focuses
only on how this facility treats alcohol use disorder.
How does this facility treat alcohol use disorder?
• These medications have been approved by the FDA to treat alcohol use disorder:
naltrexone, acamprosate, and disulfiram. For this question, MAT refers to any or all of
these three medications.
MARK ALL THAT APPLY
This facility accepts clients using MAT for alcohol use disorder, but the medications originate
from or are prescribed by another entity
This facility administers/prescribes disulfiram for alcohol use disorder
This facility administers/prescribes naltrexone for alcohol use disorder
This facility administers/prescribes acamprosate for alcohol use disorder
This facility treats alcohol use disorder, but it does not use medication-assisted treatment
(MAT) for alcohol use disorder, nor does it accept clients using MAT to treat alcohol use
disorder
This facility does not treat alcohol use disorder
*A9a. For those clients using MAT for alcohol use disorder, but whose medications originate
from or are prescribed by another entity, the clients obtain their prescriptions from:
MARK ALL THAT APPLY
A prescribing entity in our network
A prescribing entity with which our facility has a business, contractual, or formal referral
relationship
A prescribing entity with which our facility has no formal relationship
16
*A9b. Does this facility serve only alcohol use disorder clients?
o Yes
o No
*A10. Which of the following clinical/therapeutic approaches listed below are used frequently at
this facility? MARK ALL THAT APPLY FOR EACH APPROACH
CLINICAL/THERAPEUTIC
APPROACHES
OPIOID USE DISORDER
OTHER SUBSTANCES
Substance use disorder
counseling
12-step facilitation
Trauma-related counseling
Anger management
Brief intervention
Cognitive behavioral therapy
Contingency
management/motivational
incentives
Motivational interviewing
Matrix Model
Community reinforcement plus
vouchers
Relapse prevention
Telemedicine/telehealth therapy
(including Internet, Web, mobile,
and desktop programs)
Other treatment approach
(Specify:_________________)
None of the clinical/therapeutic
approaches above are offered at
this facility
17
*A11. Does this facility, at this location, offer a specially designed program or group intended
exclusively for DUI/DWI or other drunk driver offenders?
o Yes
o No
*A11a. Does this facility serve only DUI/DWI clients?
o Yes
o No
A12. Does this facility provide treatment services for…?
o Marijuana
o Stimulants
o Other substance(s) (Specify:________________________________________________ )
*A13. Does this facility provide substance use treatment services in sign language at this
location for the deaf and hard of hearing (for example, American Sign Language, Signed
English, or Cued Speech)?
▪
MARK “YES” if either a staff counselor or an on-call interpreter provides this service.
o Yes
o No
*A14. Does this facility provide substance use treatment services in a language other than
English at this location?
o Yes
o No
18
A14a. At this facility, who provides substance use treatment services in a language other than
English?
MARK ONE ONLY
o Staff counselor who speaks a language other than English
o On-call interpreter (in person or by phone) brought in when needed
o BOTH staff counselor and on-call interpreter
*A14a1. Do staff counselors provide substance use treatment in Spanish at this facility?
o Yes
o No
A14a2. Do staff counselors at this facility provide substance use treatment in any other
languages?
o Yes
o No
19
*A14b. In what other languages do staff counselors provide substance use treatment at this
facility?
• Do not count languages provided only by on-call interpreters.
MARK ALL THAT APPLY
American Indian or Alaska Native
Hopi
Lakota
Navajo
Ojibwa
Yupik
Other American Indian or Alaska Native language (Specify:__________)
Other Languages:
Arabic
Any Chinese languages
Creole
Farsi
French
German
Greek
Hebrew
Hindi
Hmong
Italian
Japanese
Korean
Polish
Portuguese
Russian
Tagalog
Vietnamese
Any Other language (Specify:_________)
20
*A15. Individuals seeking substance use treatment can vary by age, sex or other characteristics.
Which categories of individuals listed below are served by this facility, at this location?
• 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
Female
SERVED BY THIS
FACILITY
Yes
No
IF SERVED, WHAT IS
IF SERVED, WHAT IS
THE LOWEST AGE SERVED
THE HIGHEST AGE SERVED
|
|
|
Male
Yes
No
|
|
YEARS
|
|
YEARS
No minimum
age
No minimum
age
|
|
YEARS
|
|
|
YEARS
No maximum
age
No maximum
age
21
*A15a. Many facilities have clients in one or more of the following categories. For which client
categories does this facility at this location offer a substance use treatment program or group
specifically tailored for clients in that category? If this facility treats clients in any of these
categories but does not have a specifically tailored program or group for them, do not select the
box for that category.
MARK ALL THAT APPLY
Adolescents
Young adults
Adult women
Pregnant/postpartum women
Adult men
Seniors or older adults
Lesbian, gay, bisexual, transgender, or queer/questioning (LGBTQ) clients
Veterans
Active duty military
Members of military families
Criminal justice clients (other than DUI/DWI)
Clients with co-occurring mental and substance use disorders
Clients with co-occurring pain and substance use disorders
Clients with HIV or AIDS
Clients who have experienced sexual abuse
Clients who have experienced intimate partner violence, domestic violence
Clients who have experienced trauma
Specifically tailored programs or groups for any other types of clients (Specify:_____)
No specifically tailored programs or groups are offered
22
*A16. Does this facility receive any funding or grants from the Federal Government or state,
county or local governments, to support its substance use treatment programs?
Do not include Medicare, Medicaid, or federal military insurance. These forms of client payments are
included in the following question (A17).
o Yes
o No
o Don’t know
*A17. Which of the following types of client payments or insurance are accepted by this facility for
substance use treatment?
MARK ALL THAT APPLY
No payment accepted (free treatment for ALL clients)
Cash or self-payment
Medicare
Medicaid
State-financed health insurance plan other than Medicaid
Federal military insurance (for example, TRICARE)
Private health insurance
SAMHSA funding/block grants
IHS/Tribal/Urban (ITU) funds
Other (Specify: _________________________________________________ )
*A18. Is this facility a hospital or located in or operated by a hospital?
o Yes
o No
23
*A18a. What type of hospital?
MARK ONE ONLY
o General hospital (including VA hospital)
o Psychiatric hospital
o Other specialty hospital (for example, alcoholism, maternity, etc.) (Specify:__________)
A19. Does this facility operate as a skilled nursing facility (SNF) that provides services for
substance use disorders?
o Yes
o No
*A20. Does this facility operate transitional housing, a halfway house, or a sober home for
substance use clients at this location, that is, the location listed on the front cover of the paper
survey?
o Yes
o No
24
*A21. Is this facility or program licensed, certified, or accredited to provide substance use
treatment services by any of the following organizations?
• Do not include personal-level credentials or general business licenses such as a food service
license.
MARK ALL THAT APPLY
State substance use treatment agency
State mental health department
State department of health
Hospital licensing authority
The Joint Commission
Commission on Accreditation of Rehabilitation Facilities (CARF)
National Committee for Quality Assurance (NCQA)
Council on Accreditation (COA)
Healthcare Facilities Accreditation Program (HFAP)
SAMHSA certification for opioid treatment program (OTP)
Drug Enforcement Agency (DEA)
Other national organization or federal, state, or local agency (Specify:
_________________________________________________ )
This facility is not licensed, certified, or accredited to provide substance use services by
any of these organizations
25
MODULE B: MENTAL DISORDERS TREATMENT FACILITIES
B1. Does this treatment facility, at this location, offer:
MARK “YES” OR “NO” FOR EACH
Mental health intake
o Yes
o No
Mental health diagnostic evaluation
o Yes
o No
Mental health information and/or referral (also
includes emergency programs that provide
services in person or by telephone)
o Yes
o No
Mental health treatment (interventions such as
therapy or psychotropic medication that treat a
person’s mental disorder or condition, reduce
symptoms, and improve behavioral functioning
and outcomes)
o Yes
o No
Treatment for co-occurring disorders plus either
serious mental illness (SMI) in adults and/or
serious emotional disturbance (SED) in children
o Yes
o No
Substance use treatment
o Yes
o No
Administrative or operational services for mental
health treatment facilities
o Yes
o No
26
*B2. Mental health treatment is provided in which of the following service settings at this facility,
at this location?
MARK “YES” OR “NO” FOR EACH
24-hour hospital inpatient
o Yes
o No
24-hour residential
o Yes
o No
Partial hospitalization/day treatment
Outpatient
o Yes
o No
o Yes
o No
27
*B3. Which ONE category BEST describes this facility, at this location?
▪
For definitions of facility types, go to: INSERT LINK
MARK ONE ONLY
o Psychiatric hospital
o Separate inpatient psychiatric unit of a general hospital (consider this psychiatric unit as the relevant
“facility” for the purpose of this survey)
o State hospital
o Residential treatment center for children
o Residential treatment center for adults
o Other type of residential treatment facility
o Veterans Affairs Medical Center (VAMC) or other VA health care facility
o Community Mental Health Center (CMHC)
o Certified Community Behavioral Health Clinic (CCBHC)
o Partial hospitalization/day treatment facility
o Outpatient mental health facility
o Multi-setting mental health facility (non-hospital residential plus either outpatient and/or partial
hospitalization/day treatment)
o Other (Specify: _________________________________________________ )
28
B4. Is this facility either a solo or a small group practice?
o Yes
o No
*B4a. Is this facility licensed or accredited as a mental health clinic or mental health center?
▪
Do not count the licenses or credentials of individual practitioners.
o Yes
o No
B5. Does this facility, at this location, provide any of the following services?
MARK ALL THAT APPLY
Assisted living or nursing home care
Group homes
Clubhouse services
Emergency shelter (such as homeless, domestic violence, etc.)
Care for individuals with a developmental disability (that is, significant limitations in
intellectual functioning)
None of these services are offered at this facility
29
*B6. Which of these treatment modalities for mental disorders are offered at this facility, at
this location?
▪
For definitions of treatment modalities, go to: INSERT LINK
MARK ALL THAT APPLY
Individual psychotherapy
Couples/family therapy
Group therapy
Cognitive behavioral therapy
Dialectical behavior therapy
Cognitive remediation therapy
Integrated mental and substance use disorder treatment
Activity therapy (for example, art therapy)
Electroconvulsive therapy
Transcranial Magnetic Stimulation (TMS)
Ketamine Infusion Therapy (KIT)
Eye Movement Desensitization and Reprocessing (EMDR) therapy
Telemedicine/telehealth therapy (including internet, web, mobile, and desktop programs)
Abnormal Involuntary Movement Scale (AIMS) Test
Other (Specify: _________________________________________________ )
None of these mental health treatment modalities are offered at this facility
*B7. Does this facility offer the use of antipsychotics for the treatment of serious mental
illness (SMI)?
o Yes
o No
30
*B7a. Which of the following antipsychotics are used for the treatment of SMI at this facility, at
this location?
MARK ALL THAT APPLY
FIRSTGENERATION
ANTIPSYCHOTIC
NOT
USED
AT THIS
FACILITY
Chlorpromazine
Droperidol
Fluphenazine
Haloperidol
ORAL
INJECTABLE
LONG-
RECTAL
TOPICAL
DON’T
KNOW
Inhalation
ACTING
INJECTABLE
Loxapine
Perphenazine
Pimozide
Prochlorperazine
Thiothixene
Thioridazine
Trifluoperazine
Other firstgeneration
antipsychotic #1
(Specify:______)
Other firstgeneration
antipsychotic #2
(Specify:______)
Other firstgeneration
antipsychotic #3
(Specify:______)
31
SECONDGENERATION
ANTIPSYCHOTIC
NOT USED
AT THIS
FACILITY
ORAL/
SUBLINGUAL
INJECTABLE
LONG-
RECTAL
ACTING
INJECTABLE
DON’T
KNOW
TOPICAL/
TRANSDE
RMAL
Aripiprazole
Asenapine
Brexpiprazole
Cariprazine
Clozapine
IIoperidone
Lurasidone
Olanzapine
Olanzapine/
Paliperidone
Quetiapine
Risperidone
Ziprasidone
Other secondgeneration
antipsychotic #1
Fluoxetine
combination
(Specify:______)
Other secondgeneration
antipsychotic #2
(Specify:______)
Other secondgeneration
antipsychotic #3
(Specify:______)
32
*B8. Which of these services and practices are offered at this facility, at this location?
• For definitions, go to: [INSERT LINK]
MARK ALL THAT APPLY
Assertive community treatment (ACT)
Intensive case management (ICM)
Case management (CM)
Court-ordered treatment
Assisted Outpatient Treatment (AOT)
Chronic disease/illness management (CDM)
Illness management and recovery (IMR)
Integrated primary care services
Diet and exercise counseling
Family psychoeducation
Education services
Housing services
Supported housing
Psychosocial rehabilitation services
Vocational rehabilitation services
Supported employment
Therapeutic foster care
33
Legal advocacy
Psychiatric emergency walk-in services
Suicide prevention services
Peer support services
Testing for Hepatitis B (HBV)
Testing for Hepatitis C (HCV)
Laboratory tests (for example, WBC for clozapine therapy, Lithium levels, CBZ levels, valproate
levels)
Metabolic syndrome monitoring (weight, abdominal girth, BP, glucose, Hgb A1C, cholesterol,
triglycerides)
HIV testing
STD testing
TB screening
Screening for tobacco use
Smoking/vaping/tobacco cessation counseling
Nicotine replacement therapy
Non-nicotine smoking/tobacco cessation medications (by prescription)
Other(s) (Specify: ___________________)
None of these services and practices are offered at this facility
34
B9. Which of the following services are provided to clients with co-occurring mental health
and substance use at this facility?
MARK ALL THAT APPLY
Detoxification (medical withdrawal)
Medication-assisted treatment for alcohol use disorder (for example, disulfiram, acamprosate)
Medication-assisted treatment for opioid use disorder (for example, buprenorphine, methadone,
naltrexone)
Individual counseling
Group counseling
12-Step groups
Case management
Other (Specify: ___________________)
None of these services are offered at this facility
35
*B10. What age groups are accepted for treatment at this facility?
•
If any of the ages that you accept fall within a category below, mark “YES” to that category
MARK “YES” OR “NO” FOR EACH
Young children (0-5)
o Yes
o No
Children (6-12)
o Yes
o No
Adolescents (13-17)
o Yes
o No
Young adults (18-25)
o Yes
o No
Adults (26-64)
o Yes
o No
Older adults (65 or older)
o Yes
o No
36
*B11. Does this facility currently offer a mental health treatment program or group that is
dedicated or designed exclusively for clients in any of the following categories?
•
If this facility treats clients in any of these categories, but does not have a specifically tailored
program or group for them, DO NOT mark the box for that category.
MARK ALL THAT APPLY
Children/adolescents with serious emotional disturbance (SED)
Young adults
Clients 18 and older with serious mental illness (SMI)
Older adults
Clients with Alzheimer’s disease or dementia
Clients with co-occurring mental and substance use disorders
Clients with eating disorders
Clients experiencing first-episode psychosis
Clients who have experienced intimate partner violence, domestic violence
Clients with a diagnosis of post-traumatic stress disorder (PTSD)
Clients who have experienced trauma (excluding clients with a PTSD diagnosis)
Clients with traumatic brain injury (TBI)
Veterans
Active duty military
Members of military families
Lesbian, gay, bisexual, transgender, or queer/questioning (LGBTQ) clients
Forensic clients (referred from the court/judicial system)
Clients with HIV or AIDS
Other special program or group (Specify: ____________________________________________)
No dedicated or exclusively designed programs or groups are offered at this facility
37
B12. Does this facility offer a crisis intervention team that handles acute mental health issues at
this facility and/or off-site?
o Yes
o No
*B13. Does this facility offer services for psychiatric emergencies onsite?
o Yes
o No
*B14. Does this facility offer mobile/off-site psychiatric crisis services?
o Yes
o No
*B15. Does this facility provide mental health treatment services in sign language at this
location for the deaf and hard of hearing (for example, American Sign Language, Signed
English, or Cued Speech)?
•
MARK “YES” if either a staff counselor or an on-call interpreter provides this service
o Yes
o No
38
*B16. Does this facility provide mental health treatment services in a language other than English
at this location?
o Yes
o No
B16a. At this facility, who provides mental treatment services in a language other than
English?
MARK ONE ONLY
o Staff counselor who speaks a language other than English
o On-call interpreter (in person or by phone) brought in when needed
o BOTH staff counselor and on-call interpreter
*B16a1. Do staff counselors provide mental health treatment in Spanish at this facility?
o Yes
o No
B16a2. Do staff counselors at this facility provide mental health treatment in any other languages?
o Yes
o No
39
*B16b. In what other languages do staff counselors provide mental health treatment at this
facility?
•
Do not count languages provided only by on-call interpreters.
MARK ALL THAT APPLY
American Indian or Alaska Native
Hopi
Lakota
Navajo
Ojibwa
Yupik
Other American Indian or Alaska Native language (Specify:__________)
Other Languages:
Arabic
Any Chinese languages
Creole
Farsi
French
German
Greek
Hebrew
Hindi
Hmong
Italian
Japanese
Korean
Polish
Portuguese
Russian
Tagalog
Vietnamese
Any other language (Specify:_________)
40
B17. Which of these quality improvement practices are part of this facility’s standard operating
procedures?
MARK “YES” OR “NO” FOR EACH
Continuing education requirements for
professional staff
o Yes
o No
Regularly scheduled case review with a
supervisor
o Yes
o No
Regularly scheduled case review by an
appointed quality review committee
o Yes
o No
Client outcome follow-up after discharge
o Yes
o No
Continuous quality improvement processes
o Yes
o No
Periodic client satisfaction surveys
o Yes
o No
Clinical provider peer review (CPPR)
o Yes
o No
Root cause analysis (RCA)
o Yes
o No
41
B18. In the 12-month period beginning April X, 202X, and ending March XX, 202X, have staff at this
facility used:
MARK ALL THAT APPLY
Not Used at This
Facility
Chemical
Physical
Seclusion
Restrain
B18a. Does this facility have any policies in place to minimize the use of seclusion or restraint?
o Yes
o No
42
*B19. Which of the following types of client payments, insurance, or funding are accepted by this
facility for mental health treatment services?
MARK ALL THAT APPLY
Cash or self-payment
Private health insurance
Medicare
Medicaid
State-financed health insurance plan other than Medicaid
State mental health agency (or equivalent) funds
State welfare or child and family services agency funds
State corrections or juvenile justice agency funds
State education agency funds
Other state government funds
County or local government funds
Community Services Block Grants (CSBG)
Community Mental Health Services Block Grants (MHBG)
Other federal grants (specify:______________________________)
Federal military insurance (such as TRICARE)
U.S. Department of Veterans Affairs funds
IHS/Tribal/Urban (ITU) funds
Private or Community foundation
Other (Specify: ____________________________________)
43
B20. From which of these agencies or organizations does this facility have licensing, certification,
or accreditation?
• Do not include personal-level credentials or general business licenses such as a food service
license.
MARK ALL THAT APPLY
State mental health authority
State substance use treatment agency
State department of health
State or local Department of Family and Children’s Services
Hospital licensing authority
The Joint Commission
Commission on Accreditation of Rehabilitation Facilities (CARF)
Council on Accreditation (COA)
Centers for Medicare and Medicaid Services (CMS)
Other national organization, or federal, state, or local agency (Specify:
___________________________)
This facility does not have licensing, certification, or accreditation from any of these
organizations
44
MODULE C: FOR ALL TREATMENT FACILITIES
*C1. Is this facility a Federally Qualified Health Center (FQHC)?
•
FQHCs include: (1) all organizations that receive grants under Section 330 of the Public
Health Service Act; and (2) other organizations that do not receive grants, but have met the
requirements to receive grants under Section 330 according to the U.S. Department of Health
and Human Services.
•
For a complete definition of a FQHC, go to:[INSERT LINK]
o Yes
o No
o Don’t know
*C2. Is this facility operated by…
MARK ONE ONLY
o A private for-profit organization
o A private non-profit organization
o State government
o Local, county, or community government
o Tribal government
o Federal Government
*C2a. Which Federal Government agency?
MARK ONE ONLY
o Department of Veterans Affairs
o Department of Defense
o Indian Health Service
o Other (Specify:______________________)
45
C3. Is this facility affiliated with a religious (or faith-based) organization?
o Yes
o No
*C4. Which of the following statements BEST describes this facility’s smoking policy for clients?
MARK ONE ONLY
o Not permitted to smoke anywhere outside or within any building
o Permitted in designated outdoor area(s)
o Permitted anywhere outside
o Permitted in designated indoor area(s)
o Permitted anywhere inside
o Permitted anywhere without restriction
*C5. Which of the following statements BEST describes this facility’s vaping policy for clients?
MARK ONE ONLY
o Not permitted to smoke anywhere outside or within any building
o Permitted in designated outdoor area(s)
o Permitted anywhere outside
o Permitted in designated indoor area(s)
o Permitted anywhere inside
o Permitted anywhere without restriction
46
*C6. Does this facility use a sliding fee scale?
•
Sliding fee scales are based on income and other factors.
o Yes
o No
C6a. Do you want the availability of a sliding fee scale published on FindTreatment.gov, the National
Directory of Mental Health Treatment Facilities, and the National Directory of Drug and Alcohol Use
Treatment Facilities?
•
FindTreatment.gov, the National Directory of Mental Health Treatment Facilities, and the National
Directory of Drug and Alcohol Use Treatment Facilities will explain that potential clients should
call the facility for information on eligibility.
o Yes
o No
*C7. Does this facility offer treatment at no charge or minimal payment (for example, $1) to clients
who cannot afford to pay?
o Yes
o No
C7a. Do you want the availability of treatment at no charge or minimal payment (for example, $1)
for eligible clients published on FindTreatment.gov, the National Directory of Mental Health
Treatment Facilities, and the National Directory of Drug and Alcohol Use Treatment Facilities?
•
FindTreatment.gov, the National Directory of Mental Health Treatment Facilities, and the National
Directory of Drug and Alcohol Use Treatment Facilities will explain that potential clients should
call the facility for information on eligibility.
o Yes
o No
47
C8. If eligible, does this facility want to be listed on FindTreatment.gov (https://findtreatment.gov),
the National Directory of Mental Health Treatment Facilities, and the National Directory of Drug and
Alcohol Use Treatment Facilities (https://www.samhsa.gov/data)?
o Yes
o No
C8a. Does this facility want the street address and/or mailing address to be listed on
FindTreatment.gov, the National Directory of Mental Health Treatment Facilities, and the National
Directory of Drug and Alcohol Use Treatment Facilities?
MARK ALL THAT APPLY
Publish the street address
Publish the mailing address
Do not publish either address
C8b. To increase public awareness of behavioral health services, SAMHSA may be sharing
facility information with large commercially available Internet search engines (such as Google,
Bing, Yahoo!, etc.), businesses (such as any .com, .org, .edu, etc.) or individuals asking for
this information for any purpose. Do you want your facility information shared?
•
Information to be shared would be: facility name, location address, telephone number, website
address, and all asterisked items in the questionnaire.
o Yes
o No
48
C9. Is this facility part of an organization with multiple facilities or sites that provide substance use or
mental disorder treatment?
o Yes
o No
C10. What is the name, address, and phone number of the facility that is the parent, or lead site (HQ),
of the organization?
Name:
Address:
Phone Number:
49
| File Type | application/pdf |
| File Modified | 2023-08-14 |
| File Created | 2023-08-14 |