Mind Over Mood Initiative Partnership Determination Survey

Dear independent practice clinicians,

The intention of this survey tool is to help determine whether partnership with the Office of Early Childhood early childhood home visitation Mind over Mood Initiative may be a fit for you. We expect anyone who is interested in attending our partnership training complete this questionnaire. Completed questionnaires are reviewed by our project coordination team. Selected clinicians are invited to participate in training to connect with your practice in a more relational way. Clinicians are selected based on experience working clinically with mothers in their homes, training and experience providing treatment from an attachment, infant mental health and perinatal mental health framework. Training and experience in Perinatal Mood and Anxiety Disorders. This tool will help you better gauge your readiness for participation. Thank you for taking the time to complete this survey. You will receive a response from Claudia Liloy or Jen Vendetti. If you have specific questions, email Jen at Jvendetti@uchc.edu

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* 1. Practice Contact Information

Name *

Credentials

Address *

Address 2

City/Town *

ZIP/Postal Code *

Email Address *

Phone *

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* 2. If applicable, what is your fax number?

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* 3. If applicable, what is the name of the independent group practice you are part of?

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* 4. Are you an independent practice clinician in Connecticut?

Yes, full time private/small independent group practice

Yes, part time private/small independent group practice

No, I'm in the planning stages

No, I work for an agency-based practice

Other (please specify)

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* 5. Are you credentialed as a Husky behavioral health provider?

Yes, and I've billed Husky successfully

Yes, but I haven't billed Husky yet

No, I am currently in the process

No, not yet

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* 6. Have you ever provided psychotherapy in families' homes?

Yes, I have past and current home-based tx experience and training

Yes, I have past home-based tx experience and training

Yes, but limited experience providing services in the home

No, but I am willing to expand my practice to include home-based tx

Other (please specify)

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* 7. Which of the following areas are you be willing to provide home-based services in?

Waterbury

Danbury

Norwalk

Stamford/Greenwich

Putnam

Norwich

New London

Torrington

New Britain

Hartford

Meriden

Middletown

New Haven

Please specify what towns you are willing to provide home-based services in

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* 8. Do you provide psychotherapy in Spanish?

Yes

Specify other practicing language

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* 9. Tell us about your experience working with pregnant and postpartum mothers experiencing depression or anxiety?

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* 10. What is your experience working with early childhood home visitation?

I have worked in home-based prevention services

I have worked in home-based clinical services

I have worked in child welfare services

I have worked in early intervention services

I have worked in collaboration with home visitation services

I have no experience working with home-based early childhood services

Other (please specify)

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* 11. What is your experience working with early childhood home visitation?

I have worked in home-based prevention services

I have worked in home-based clinical services

I have worked in child welfare services

I have worked in early intervention services

I have worked in collaboration with home visitation services

I have no experience working with home-based early childhood services

Other (please specify)

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* 12. What is your training and experience treating Perinatal Mood and Anxiety Disorders

I have formal training and experience in treating PMADs

I have formal training but limited experience in treating PMADs

Limited training and experience treating these disorders

My practice specializations include:

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* 13. What is your training and experience treating Perinatal Mood and Anxiety Disorders

I have formal training and experience in treating PMADs

I have formal training but limited experience in treating PMADs

Limited training and experience treating these disorders

My practice specializations include:

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* 14. What is your training and experience in dyadic work?

I have formal training and experience working with parents and infants/young children

I do not have formal training but I have worked with parent-infant dyads

I am hoping to learn more about attachment-based practice/working with mother-child dyads

Other (please specify)

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* 15. What is your hope and expectation for client referrals?

I hope/expect a steady stream of referrals from the home visiting site I am partnered with

I hope/expect one or two active cases at a time from my partnered home visiting site

I have no specific hope/expectation for referrals but want to be in a partnering role with my local home visiting program

I have no client openings at this time

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* 16. How would you describe your referral availability?

I often have multiple openings

I often have one or two available openings

I am often at capacity and have a waiting list

I am often full during the day but have evening and weekend availability

I only offer my practice evenings and weekends

Other (please specify)

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* 17. Are you willing to complete a brief Treatment Summary Form (no client identifiers)?

Yes

I need to learn more