Directory Questionnaire

We request the completion of the following survey in an effort to ensure that we have an up-to-date provider directory for trauma-specific treatments and resources in the community.  Collected information will be used to update the current public directory of Trauma-Informed, Trauma-Sensitive and Trauma-Specific Services, interventions, treatments and resources guide which was created by Trauma-Informed Community Initiative of Western New York and will continue to be housed on the TICI of WNY website (https://www.ticiwny.com/).  Please complete the survey as thoroughly as possible. 

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* 1. What is today’s date?

Date / Time

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* 2. Organization/Provider General Demographic Information

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* 3. What is the name of the contact person for this organization/provider?

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* 6. Is the site accessible to public transportation?

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* 7. Which of the following modes of transportation are accessible to the site?

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* 8. Is the site accessible to a person with a disability?

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* 9. What languages are spoken at your site for clients?

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* 10. What are the hours of operation?

  Daytime appointments Evening appointments 24 hr availability (check box) Appointment Only (check box) Walk-in availability N/A
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

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* 11. Please check all that apply

  Children 1-5 Children 6-12 Adolescents Adults Geriatrics
Mental Health Counseling/Services
Substance Use Counseling/Services
Mental Health and Substance Use Counseling/Services

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* 12. Trauma-Informed, Trauma-Sensitive, Trauma-Specific Interventions, Treatments and Resources

  Yes No N/A
Trauma Focused-Cognitive Behavior Therapy (TF-CBT)
Narrative Therapy
Eye Movement Desensitization and Reprocessing (EMDR)
Cognitive Processing Therapy (CPT)
Exposure Therapy
Skills Training in Affective and Interpersonal Regulation (STAIR)
Stress Inoculation Training (SIT)
Addiction and Trauma Recovery Integration Model (ATRIUM)
Seeking Safety
Substance Dependence PTSD Therapy
Trauma Recovery and Empowerment Model

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