A. Demographic Information

As a behavioral health provider agency/organization within Maine, your response to the survey helps state planners in several ways, providing for (1) an assessment of agency/ organization level of preparedness, (2) identification of resources to foster coalitions that strengthen the state’s preparedness efforts, and (3) enhancement of preparedness, response and recovery activities through statewide collaboration. Your response, which will be held in confidence, helps set the stage for a cohesive state unit acting as a system to provide integration, coordination and organization for regional preparedness.

Please respond by June 28, 2017

* 1. Identify the type of agency/organization you are replying on behalf of.

* 2. Identify the name of your agency/organization.

* 3. Name of the individual completing this survey and an email address.

* 4. Identify the physical location(s) of your agency/organization.

* 5. Identify the geographic location(s) of the populations your agency/organization serves.

* 6. Identify the types of services your agency/organization provides.

* 7. How are your services provided?