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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 Kathy Novak or Jen Vendetti.  If you have specific questions, email Jen at Jvendetti@uchc.edu

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* 1. Practice Contact Information

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* 2. Do you have a fax machine or computer/smartphone based fax capability?

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

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

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

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

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

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

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* 9. Do you provide psychotherapy in Spanish?

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

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

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

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

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

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* 15. How would you describe your referral availability?

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

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