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

Date

Time

AM/PM

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* 2. Organization/Provider General Demographic Information

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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

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* 4. What is the classification of the organization?

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* 5. What Type of Agency?

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* 6. Is the site accessible to public transportation?

Yes

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

Bus

Train

Other (please specify)

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

Yes

Other (please specify)

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

English

Spanish

French

Farsi

Tagalog

Vietnamese

Portuguese

Korean

American Sign Language

Chinese (please specify dialect in other field)

Other (please specify)

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

Other (please specify)

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* 11. Please check all that apply

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

Other (please specify)

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

Other Interventions/Treatments/Resources (please specify)

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* 13. What insurance is accepted? Select all that apply

Blue Cross/Blue Shield of WNY

Independent Health

Wellcare

Fidelis

Medicaid

Medicare

Univera

United

Other (please specify)

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* 14. What financial assistance policies are in place? Select all that apply

Sliding-Scale

Payment Plans

Other (please specify)