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* 1. Name

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* 2. Group or practice name (if applicable)

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* 3. Service Address

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* 4. County and State

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* 5. Phone

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* 6. Email

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* 7. Please select your professional behavioral health license and certification:

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* 8. Please select the areas of specialization you provide (please select all that apply)

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* 9. What populations do you serve? Please select all that apply.

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* 10. Which of these mental health treatment approaches do you offer? Please select all that apply.

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* 11. Do you provide mental health services in a language other than English? If yes, please enter the languages

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* 12. Who provides mental health treatment services in a language other than English? Mark one only:

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* 13. How many sessions/hours do you currently provide for clients on a weekly basis?

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* 14. Approximately how often do you refer clients to other providers because you do not have time available to see them?

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* 15. Approximately how often to you refer clients to other providers because of patient-provider fit?

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* 16. Are you accepting new patients at this time?

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* 17. What is the average time between when a new client first reaches out for services (i.e. phone call, online appointment request) and their first date of receiving treament (excluding intake or screening)?

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* 18. On average, how often (at what frequency) are the majority of your clients seen after an intake?

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* 19. Which of the following types of clients payments, insurance or funding are accepted by this facility or provider for mental health treatment services? Select all that apply

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* 20. If you accept commercial insurance, what percentage of your current clients utilize their insurance to pay for services with you?

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* 21. For cash or self-payment, do you offer a sliding scale based on ability to pay?

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* 22. If you do not accept commercial insurance, could you explain why?

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* 23. If your credentialing fees and billing management for all insurance claims were paid for by Building Hope, would you be willing to accept more types of patient insurance?

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* 24. Do you provide tele-therapy services (i.e. therapy sessions conducted over secure video platform)?

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* 25. If not, do you refer clients to other providers for tele-therapy?

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* 26. On average, how many clients do you either refer to tele-therapy of directly provide tele-therapy to each month?

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* 27. Which of these crisis services do you provide, if any? Please check all that apply

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* 28. If you do provide crisis services, do you provide them for new clients, current clients or both?

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* 29. If yes, how many hours do you reserve each week for crisis services?

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* 30. Would you be willing to reserve crisis hours (or additional crisis hours) in exchange for partial compensation if they were not filled?

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* 31. If yes, what percentage of your regular fee would you be willing to set aside hours for?

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* 32. If yes, how many hours would you be willing to set aside per week?

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* 33. If not, do you have a local option to which you can confidently refer people in crisis?

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* 34. In an effort to understand provider availability across Summit County, these next questions will ask you about the platform(s) you currently use for scheduling and billing as well as shared platforms you may be open to using.

What kind of patient record keeping system do you currently use?

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* 35. If you currently use an electronic record keeping system, which one do you use?

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* 36. Do you currently use a practice management software or platform (such as Let’s Talk, Simple Practice, Penelope, etc.)?

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* 37. If yes, which practice management software or platform do you currently use?

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* 38. What feature(s) do you currently utilize most on your practice management platform? Please select all that apply.

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* 39. Would you be willing to use a shared universal practice management platform, with booked versus open hours visible to Building Hope Navigators, if it was secure, HIPAA compliant, did not disclose the names of clients to any user but you, and was provided free of charge or at a low cost?

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* 40. If you had access to a practice management platform provided free-of-charge/at a low cost to you, which services would you be likely to use? Please check all that apply.

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* 41. In an effort to get clients connected to care faster, would you be willing to be part of an online, easy-to-use referral process that allowed you to accept or decline referral clients?

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* 42. What other methods would you be willing to use to help Building Hope understand provider availability and make referrals in Summit County? Please check all that apply.

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* 43. In what areas would you be most interested in receiving free or reduced cost training?

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* 44. Have you attended any workforce trainings that you would recommend to others?

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* 45. If yes, please share with us which trainings

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* 46. For those of you who just credentialed with Peak Health Alliance - Bright and Rocky Mountain Health Plans) would you be interested in an informational session about basic billing and carrier info 101?

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