Question Title

* 1. Please tell us a little about yourself and your practice.

Question Title

* 2. What is the average wait time for an initial appointment with a new patient.

Question Title

* 3. Do you have a consulting and referral relationship with a primary care medical group? If so, please note the group.

Question Title

* 4. Answer the following questions by clicking either Yes or No. If you have additional comments, please use the text box below.

  Yes No
Do you treat patients between the ages of 65 and 75 years old?
Do you treat patients who are older than 75 years?
If you are not a prescribing physician yourself, do you have a relationship with a psychiatrist or a psychiatric clinical nurse specialist?
Do you participate in multidisciplinary treatment teams including medical practitioners?
Do you provide services in a patient's place of residence when clinically necessary?
Do you accept patients who are seeking substance abuse treatment?
Do you accept dual diagnosis patients (those affected by both mental health and substance abuse)?
Do you accept patients with comorbid chronic medical illness?
Do you perform neuropsychological testing and assessment?
Do you perform consultation to, and onsite services at, Skilled Nursing Facilities?

Question Title

* 5. Please answer the following questions. If yes, please explain further in the comment box and indicate if anything varies dependent on the age of the patient.

  Yes No
Do you specialize in treating any particular conditions?
Do you specialize in any particular approaches to treatment?

Question Title

* 6. Check all that apply. If you have additional comments, please use the text box below.

  Patients 65 years or older Substance use as a primary diagnosis Patients with comorbid chronic medical illness
As part of your advanced degree, did your coursework specifically address any of the following:
Within the past ten years, have you completed continuing education units on any of the following topics:
Do you have experience working in an agency or program specialized in treating any of the following:

Question Title

* 7. Please complete the survey by answering the following two questions.

  Yes No
Would you be interested in forming a relationship with Primary Care Physicians (PCP) looking for a behavioral health resource?
If yes, may we provide your name, contact information and your responses to this survey to one or more PCPs in your community who are interested in relationships with behavioral health resources?

Question Title

* 8. If you have any further comments, questions or concerns, please share them in the text box below. Thank you for taking the time to provide us with this valuable information. We will use it to ensure that the information we provide our members enables them to quickly find the right practitioner for their situation.

T