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Provider Telehealth Survey
Technology-related Items
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1.
Please provide your first and last name.
(Required.)
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2.
What is your email address?
(Required.)
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3.
What is the name of your organization?
(Required.)
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4.
Please indicate for which specific services your agency has implemented Telehealth. Please select all that apply.
(Required.)
MHOP Individual Therapy
MHOP Group Therapy
MHOP Medication Visit
MHOP Partial Hospital
MHOP Assertive Community Treatment (ACT)
Outpatient D&A Individual Therapy
Outpatient D&A Group Therapy
Outpatient D&A Medication Assisted Treatment
MH Case Management
Psychiatric Rehabilitation Individual Services
Psychiatric Rehabilitation Group Services
Adult Residential Treatment
Children’s Residential Treatment (PRTF, RTF)
Psychiatric Inpatient Treatment
Family-Based Mental Health Services
Intensive Behavioral Health Services (IBHS)/ Behavioral Health Rehabilitation Services (BHRS)
Peer Support Services Certified Peer Support Specialists
Peer Support Services Certified Recovery Specialist Services
Other (please specify)
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5.
What specific equipment is being predominately utilized by direct care staff of your organization to facilitate Telehealth (e.g. agency laptop computers, cell phone, etc.)
(Required.)
Company-issued laptop
Personal laptop
Company-issued desktop computer
Personal desktop computer
Company-issued tablet
Personal tablet
Company-issued cell phone
Personal cell phone
Company landline
Personal landline
Other (please specify):
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6.
What Telehealth platform is being utilized by your organization to offer Telehealth?
(Required.)
Zoom for Healthcare
Skype
Doxy
GoToMeeting
thera-LINK
FaceTime
VSee
Other (please specify):
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7.
Is this Telehealth platform HIPAA-compliant?
(Required.)
Yes
No
Not sure
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8.
Has your organization implemented an Electronic Health Record (EHR)?
(Required.)
Yes
No
Current Progress,
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