Partners' Child/Adolescent Residential Provider Survey

Child/Adolescent Residential Provider Input/Feedback Requested

Partners is always looking for ways to garner feedback and input from our providers. We are seeking feedback regarding our child/adolescent residential providers. The information collected in this survey will help us develop additional information sharing and outreach to ensure members are able to access needed child/adolescent residential services. Thank you for taking the time to provide some information. Please complete this survey by January 3, 2025.

Question Title

* 1. Provider Contact Information

Name *

Company

Address

City/Town

State/Province

ZIP/Postal Code

Email Address *

Phone Number *

Question Title

* 2. Practice/Agency Tax ID Number:

Question Title

* 3. What Residential Services are you currently contracted with Partners' to provide? Please check all that apply.

Intensive Alternative Family Treatment (IAFT)

Therapeutic Foster Care

Residential Level II

Residential Level III

Residential Level IV (0-4 beds)

Residential Level IV (5+ beds)

Psychiatric Residential Treatment Facility (PRTF)

Other (please specify)

Question Title

* 4. Are you currently receiving referrals from Partners

Yes

Other (please specify)

Question Title

* 5. Are you currently ACCEPTING Referrals from Partners

Yes

Other (please specify)

Question Title

* 6. If you answered that you are not accepting referrals from Partners, can you tell us the reason.

Question Title

* 7. Do you have any special admission requirements (example: only take DSS children, Need specific items/assessments for admission to your program)

Yes

If yes, please share these requirements

Question Title

* 8. Do you delineate beds/homes by gender (example, are all your beds for females or males or other gender specific criteria).

Male beds only

Female beds only

Coed

Other (please specify)

Question Title

* 9. Do you only provide residential services in NC?

Yes

If no, what other States do you provide services in?

Question Title

* 10. What age groups do you currently serve? Please check all that apply

0-5

6-11

12-18

Other (please specify)

Question Title

* 11. Do you provide any specialized programming that you would like Partners to know about? Please check all that apply.

Trauma Informed Care

Problem Sexualized Behaviors

Sexual Offender Treatment

Human Trafficking

Autism

Medically Fragile

Substance Use

Intellectually/Developmental Disabled Population - Mild

Intellectually/Developmental Disabled Population - Moderate

Dually Diagnosed - MH/SUD

Dually Diagnosed - MH/IDD

Gender Specific Treatment - Male

Gender Specific Treatment - Female

Gender Specific - LGBTQ+

Other (please specify)

Question Title

* 12. What barriers are you experiencing in accepting/serving Partners' members?

Lack of Referrals

Inappropriate referrals

Rates

Admission requirements barriers

Other (please specify)

Question Title

* 13. If you checked any barriers/noted barriers in Q13, please share additional information that would be helpful for Partners to understand.

Question Title

* 14. Would a Child/Adolescent Learning Collaborative be beneficial to you as a provider in Partners' network?

Yes

Other (please specify)

Question Title

* 15. Please let us know if a follow up conversation would be beneficial?

Yes

Other (please specify)

Partners' Child/Adolescent Residential Provider Survey

Child/Adolescent Residential Provider Input/Feedback Requested

Question Title

* 1. Provider Contact Information

Question Title

* 2. Practice/Agency Tax ID Number:

Question Title

* 3. What Residential Services are you currently contracted with Partners' to provide? Please check all that apply.

Question Title

* 4. Are you currently receiving referrals from Partners

Question Title

* 5. Are you currently ACCEPTING Referrals from Partners

Question Title

* 6. If you answered that you are not accepting referrals from Partners, can you tell us the reason.

Question Title

* 7. Do you have any special admission requirements (example: only take DSS children, Need specific items/assessments for admission to your program)

Question Title

* 8. Do you delineate beds/homes by gender (example, are all your beds for females or males or other gender specific criteria).

Question Title

* 9. Do you only provide residential services in NC?

Question Title

* 10. What age groups do you currently serve? Please check all that apply

Question Title

* 11. Do you provide any specialized programming that you would like Partners to know about? Please check all that apply.

Question Title

* 12. What barriers are you experiencing in accepting/serving Partners' members?

Question Title

* 13. If you checked any barriers/noted barriers in Q13, please share additional information that would be helpful for Partners to understand.

Question Title

* 14. Would a Child/Adolescent Learning Collaborative be beneficial to you as a provider in Partners' network?

Question Title

* 15. Please let us know if a follow up conversation would be beneficial?

Question Title

* 16. Anything else you think would be beneficial to share?