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Thank you for participating in the PMH Learning Community!

Please complete this baseline survey for the hospital you are representing.

The survey will capture - for each participating hospital - the current practices regarding perinatal mental health patient education, screening, and referrals; existing documented policies and protocols; and anticipated needs for technical assistance and coaching.

We recommend that you begin by downloading a PDF version of the survey here and then use the paper version as a worksheet. This will allow you to review the questions and, if needed, consult with internal colleagues before providing answers into the online survey.

When you are ready, please enter the responses into the online survey below. The survey allows you to edit responses, as needed, until you click "done" for the final submission. Your answers will be lost if you exit the survey before clicking “done”.

If you are responding on behalf of multiple hospitals, please complete a separate survey for each hospital one at a time.

If you have questions, please contact Julia Slininger, RN,BS,CPHQ Program Manager, Perinatal Mental Health Initiative at jslininger@hqinstitute.org or (213) 453-4519.

We are grateful for your time and participation!


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* 1. What is the name and location of the hospital you are representing?

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* 2. Which of the following patient education resources about perinatal mental health disorders does your hospital currently offer? (Perinatal mental health disorders are defined as mental health disorders that may occur throughout the prenatal and postpartum periods.)

  Yes No
Verbal information delivered to patients
Posters / information displays
Brochures for patients
Patient-facing apps (e.g., downloaded to device)
Online resources (e.g., hospital website)

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* 3. Does your hospital reliably track which patients have received patient education about perinatal mental health disorders?

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* 4. If yes, approximately what percentage of perinatal patients at your hospital receive some form of patient education about perinatal mental health disorders prior to hospital discharge?

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* 5. How much support from our PMH Learning Community (e.g., technical assistance, coaching) do you anticipate needing for your hospital to improve patient education practices about perinatal mental health disorders?

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* 6. Does your hospital currently offer any of the following education or training to hospital employees regularly assigned to work in perinatal units (including but not limited to  nurses, social workers, and doctors)?

  Yes No
Education for employees about the signs and symptoms of perinatal mental health disorders
Training about how to screen for perinatal mental health disorders in clinical settings using evidence-based tools
Training about how to talk with patients who may be experiencing perinatal mental health disorders
Training about how to refer patients and referral resources

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* 7. How much support from our PMH Learning Community (e.g., technical assistance, coaching) do you anticipate needing for your hospital to offer these (or other) types of education for hospital employees?

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* 8. Does your hospital have written procedures and protocols surrounding screening and referrals for perinatal mental health disorders before hospital discharge?

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* 9. Does your hospital currently screen women in the perinatal period for mental health disorders (e.g, anxiety, depression or other mood disorders, or other mental health problems)?

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* 10. If yes, which of the following evidence-based screening tools are used to identify women who may be experiencing symptoms in the perinatal period? (Select more than one, if applicable.)

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* 11. If "other" screening tool or protocol is used, please describe in the space below.

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* 12. Does your hospital currently review data on perinatal mental health screening rates? Specifically, this includes data about patients eligible for screening, those screened, and the screening result.

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* 13. If "yes" to question #12, approximately what percentage of patients are currently screened before hospital discharge? (If "no" to question #12, please skip to #15)

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* 14. To whom in the organization are perinatal mental health screening rates reported?

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* 15. How much support (e.g., training, coaching) from our PMH Learning Community do you anticipate needing for your hospital to improve screening practices and protocols for perinatal mental health disorders?

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* 16. Does your hospital currently offer information to patients about support groups, counselors, or other services (in-house or community-based) that are available for self-referral?

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* 17. How confident are you that the information for patients is up-to-date and accurate?

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* 18. Which of the following resources are maintained by your hospital to assist staff with referring patients for  further evaluation, support, or treatment?

  Yes No
Lists of support groups
Contact information for in-house mental and behavioral health, social workers, and other resources
Contact information for community-based providers
Lists of community organizations
Other resources

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* 19. Please use the space below to describe "other resources" maintained by your hospital to assist staff with referring patients for further evaluation, support, or treatment.

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* 20. How confident are you that this information to assist staff with referring patients is up-to-date and accurate?

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* 21. Is there a mechanism to review how timely patients are seen after being referred?

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* 22. Would you like to share any additional information about your hospital's practices, procedures, or resources relevant to perinatal mental health?

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* 23. What is your name, title, and email address? (This is required for project use only!)

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