This survey is intended to gather information regarding mental health and psychiatric services currently being provided in rural hospitals in the State of Mississippi and the role that telepsychiatry may play to support these needed services in our communities. We thank you in advance for your feedback. This survey is provided in partnership with the University of Mississippi Medical Center, Center for Telehealth, as part of its National Center of Excellence.

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* 1. Please complete the following for the individual completing this survey

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* 3. What is the name of your facility?

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* 4. Do you currently offer mental health / psychiatric clinical services in your hospital?

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* 5. What specific needs do you currently have for psychiatric / mental health clinical services? Inpatient, outpatient, substance use, etc

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* 6. Do you currently offer emergency psychiatric services?

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* 7. Do you currently admit patients to your hospital for mental health / psychiatric needs?

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* 8. Who currently provides emergency psychiatric services at your hospital?

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* 9. What is the approximate volume of need for mental health services in your emergency room on a daily basis?

Less than 1 patient per day 50+ patients per day
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i We adjusted the number you entered based on the slider’s scale.

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* 10. What is your estimated payor mix? (Should total 100%)

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* 11. Other than services that your hospital may provide, how far away is the nearest facility available to treat mental health and psychiatric needs?

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* 12. Do you have any agreement with a mental health / psychiatric treatment facility in your area?

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