Behavioral Health Survey | Driscoll Health Plan

The survey is estimated to take about 10-15 minutes to complete. The information gleaned will be used to more appropriately refer future patients and to invite your participation in future educational or training efforts. The person completing the survey should answer collectively for the entity credentialed with the Health Plan.

It must be completed in a single sitting.

Organization's Name*

Person Completing Survey*

Position*

In the last 3 months, how many children in each (diagnosis x age) group have you evaluated or treated

Diagnosis

Age 2-5 Years

Age 6-12 Years

Age 13-21 years

Depression / suicidal thoughts / self-harm

Age 2-5 Years

Age 6-12 Years

Age 13-21 years

ADHD and disruptive disorders

Age 6-12 Years

Age 13-21 years

Anxiety disorders

Age 2-5 Years

Age 6-12 Years

Age 13-21 years

Sexual abuse and other trauma

Age 2-5 Years

Age 6-12 Years

Eating disorders

Age 2-5 Years

Age 6-12 Years

Age 13-21 years

Autism, intellectual disability or other developmental disorders

Age 2-5 Years

Age 6-12 Years

Age 13-21 years

Coping with medical problems (diabetes, cystic fibrosis, pain, obesity, cancer, heart disease)

Age 2-5 Years

Age 6-12 Years

Age 13-21 years

Dyslexia and other learning disorders

Age 2-5 Years

Age 6-12 Years

Age 13-21 years

Schizophrenia, bipolar

Age 2-5 Years

Age 6-12 Years

Age 13-21 years

Gender identity

Age 2-5 Years

Age 6-12 Years

Age 13-21 years

Drug and alcohol abuse

Age 2-5 Years

Age 6-12 Years

Age 13-21 years

On a scale of 1 to 5, how well-trained or experienced do you rate yourself in each (diagnosis x age) group.

*All fields are required in this section. 1 indicates no expertise, 2 indicates minimal, 3 moderate, 4 well-developed, and 5 expert-level.

Diagnosis

Age 2-5 Years

Age 6-12 Years

Age 13-21 years

Depression / suicidal thoughts / self-harm

EXPERIENCE: Depression/Suicidal Thoughts/Self-Harm Age 2-5 Years*

EXPERIENCE: Depression/Suicidal Thoughts/Self-Harm Age 6-12 Years*

EXPERIENCE: Depression/Suicidal Thoughts/Self-Harm Age 13-21 years*

ADHD and disruptive disorders

EXPERIENCE: ADHD and Disruptive Disorders Age 2-5 Years*

EXPERIENCE: ADHD and Disruptive Disorders Age 6-12 Years*

EXPERIENCE: ADHD and Disruptive Disorders Age 13-21 Years*

Anxiety disorders

EXPERIENCE: Anxiety Disorders Age 2-5 Years*

EXPERIENCE: Anxiety Disorders Age 6-12 Years*

EXPERIENCE: Anxiety Disorders Age 13-21 Years*

Sexual abuse and other trauma

EXPERIENCE: Sexual Abuse and Other Trauma Age 2-5 Years*

EXPERIENCE: Sexual Abuse and Other Trauma Age 6-12 Years*

EXPERIENCE: Sexual Abuse and Other Trauma Age 13-21 Years*

Eating disorders

EXPERIENCE: Eating Disorders Age 2-5 Years*

EXPERIENCE: Eating Disorders Age 6-12 Years*

EXPERIENCE: Eating Disorders Age 13-21 Years*

Autism, intellectual disability or other developmental disorders

EXPERIENCE: Autism, intellectual disability or other developmental disorders Age 2-5 Years*

EXPERIENCE: Autism, intellectual disability or other developmental disorders Age 6-12 Years*

EXPERIENCE: Autism, intellectual disability or other developmental disorders Age 13-21 Years*

Coping with medical problems (diabetes, cystic fibrosis, pain, obesity, cancer, heart disease)

EXPERIENCE: Coping Age 2-5 Years*

EXPERIENCE: Coping Age 6-12 Years*

EXPERIENCE: Coping Age 13-21 Years*

Dyslexia and other learning disorders

EXPERIENCE: Dyslexia and other learning disorders Age 2-5 Years*

EXPERIENCE: Dyslexia and other learning disorders Age 6-12 Years*

EXPERIENCE: Dyslexia and other learning disorders Age 13-21 Years*

Schizophrenia, bipolar

EXPERIENCE: Schizophrenia, bipolar Age 2-5 Years*

EXPERIENCE: Schizophrenia, bipolar Age 6-12 Years*

EXPERIENCE: Schizophrenia, bipolar Age 13-21 Years*

Gender identity

EXPERIENCE: Gender identity Age 2-5 Years*

EXPERIENCE: Gender identity Age 6-12 Years*

EXPERIENCE: Gender identity Age 13-21 Years*

Drug and alcohol abuse

EXPERIENCE: Drug and alcohol abuse Age 2-5 Years*

EXPERIENCE: Drug and alcohol abuse Age 6-12 Years*

EXPERIENCE: Drug and alcohol abuse Age 13-21 Years*

Parent behavior training (e.g. Triple P)

EXPERIENCE: Parent behavior training Age 2-5 Years*

EXPERIENCE: Parent behavior training Age 6-12 Years*

EXPERIENCE: Parent behavior training Age 13-21 Years*

In what areas have you received specialized, supervised training as part of an internship or certification? CEUs without supervised practice do not count here.

Diagnosis

Age 2-5 Years

Age 6-12 Years

Age 13-21 years

Depression / suicidal thoughts / self-harm

TRAINING/CERTIFICATION: Depression/Suicidal Thoughts/Self-Harm Ages 2-5*

TRAINING/CERTIFICATION: Depression/Suicidal Thoughts/Self-Harm Ages 6-12*

TRAINING/CERTIFICATION: Depression/Suicidal Thoughts/Self-Harm Ages 13-21*

ADHD and disruptive disorders

TRAINING/CERTIFICATION: ADHD and disruptive disorders Ages 2-5*

TRAINING/CERTIFICATION: ADHD and disruptive disorders Ages 6-12*

TRAINING/CERTIFICATION: ADHD and disruptive disorders Ages 13-21*

Anxiety disorders

TRAINING/CERTIFICATION: Anxiety disorders Ages 2-5*

TRAINING/CERTIFICATION: Anxiety disorders Ages 6-12*

TRAINING/CERTIFICATION: Anxiety disorders Ages 13-21*

Sexual abuse and other trauma

TRAINING/CERTIFICATION: Sexual abuse and other trauma Ages 2-5*

TRAINING/CERTIFICATION: Sexual abuse and other trauma Ages 6-12*

TRAINING/CERTIFICATION: Sexual abuse and other trauma Ages 13-21*

Eating disorders

TRAINING/CERTIFICATION: Eating disorders Ages 2-5*

TRAINING/CERTIFICATION: Eating disorders Ages 6-12*

TRAINING/CERTIFICATION: Eating disorders Ages 13-21*

Autism, intellectual disability or other developmental disorders

TRAINING/CERTIFICATION: Autism, intellectual disability or other developmental disorders Ages 2-5*

TRAINING/CERTIFICATION: Autism, intellectual disability or other developmental disorders Ages 6-12*

TRAINING/CERTIFICATION: Autism, intellectual disability or other developmental disorders Ages 13-21*

Coping with medical problems (diabetes, cystic fibrosis, pain, obesity, cancer, heart disease)

TRAINING/CERTIFICATION: Coping Ages 2-5*

TRAINING/CERTIFICATION: Coping Ages 6-12*

TRAINING/CERTIFICATION: Coping Ages 13-21*

Dyslexia and other learning disorders

TRAINING/CERTIFICATION: Dyslexia and other learning disorders Ages 2-5*

TRAINING/CERTIFICATION: Dyslexia and other learning disorders Ages 6-12*

TRAINING/CERTIFICATION: Dyslexia and other learning disorders Ages 13-21*

Schizophrenia, bipolar

TRAINING/CERTIFICATION: Schizophrenia, bipolar Ages 2-5*

TRAINING/CERTIFICATION: Schizophrenia, bipolar Ages 6-12*

TRAINING/CERTIFICATION: Schizophrenia, bipolar Ages 13-21*

Gender identity

TRAINING/CERTIFICATION: Gender identity Ages 2-5*

TRAINING/CERTIFICATION: Gender identity Ages 6-12*

TRAINING/CERTIFICATION: Gender identity Ages 13-21*

Drug and alcohol abuse

TRAINING/CERTIFICATION: Drug and alcohol abuse Ages 2-5*

TRAINING/CERTIFICATION: Drug and alcohol abuse Ages 6-12*

TRAINING/CERTIFICATION: Drug and alcohol abuse Ages 13-21*

Parent behavior training (e.g. Triple P)

TRAINING/CERTIFICATION: Parent behavior training (e.g. Triple P) Ages 2-5*

TRAINING/CERTIFICATION: Parent behavior training (e.g. Triple P) Ages 6-12*

TRAINING/CERTIFICATION: Parent behavior training (e.g. Triple P) Ages 13-21*

Please write the name(s) of the certification or training program(s):

Please identify which (age x diagnosis) groups you would be willing to provide more services or receive more training to qualify yourself to provide those services.

Diagnosis

Age 2-5 Years

Age 6-12 Years

Age 13-21 years

Depression / suicidal thoughts / self-harm

MORE SERVICES: Depression/Suicidal Thoughts/Self-Harm Ages 2-5*

MORE SERVICES: Depression/Suicidal Thoughts/Self-Harm Ages 6-12*

MORE SERVICES: Depression/Suicidal Thoughts/Self-Harm Ages 13-21*

ADHD and disruptive disorders

MORE SERVICES: ADHD and disruptive disorders Ages 2-5*

MORE SERVICES: ADHD and disruptive disorders Ages 6-12*

MORE SERVICES: ADHD and disruptive disorders Ages 13-21*

Anxiety disorders

MORE SERVICES: Anxiety disorders Ages 2-5*

MORE SERVICES: Anxiety disorders Ages 6-12*

MORE SERVICES: Anxiety disorders Ages 13-21*

Sexual abuse and other trauma

MORE SERVICES: Sexual abuse and other trauma Ages 2-5*

MORE SERVICES: Sexual abuse and other trauma Ages 6-12*

MORE SERVICES: Sexual abuse and other trauma Ages 13-21*

Eating disorders

MORE SERVICES: Eating disorders Ages 2-5*

MORE SERVICES: Eating disorders Ages 6-12*

MORE SERVICES: Eating disorders Ages 13-21*

Coping with medical problems (diabetes, cystic fibrosis, pain, obesity, cancer, heart disease)

MORE SERVICES: Coping Ages 2-5*

MORE SERVICES: Coping Ages 6-12*

MORE SERVICES: Coping Ages 13-21*

Dyslexia and other learning disorders

MORE SERVICES: Dyslexia and other learning disorders Ages 2-5*

MORE SERVICES: Dyslexia and other learning disorders Ages 6-12*

MORE SERVICES: Dyslexia and other learning disorders Ages 13-21*

Schizophrenia, bipolar

MORE SERVICES: Schizophrenia, bipolar Ages 2-5*

MORE SERVICES: Schizophrenia, bipolar Ages 6-12*

MORE SERVICES: Schizophrenia, bipolar Ages 13-21*

Gender identity

MORE SERVICES: Gender identity Ages 2-5*

MORE SERVICES: Gender identity Ages 6-12*

MORE SERVICES: Gender identity Ages 13-21*

Drug and alcohol abuse

MORE SERVICES: Drug and alcohol abuse Ages 2-5*

MORE SERVICES: Drug and alcohol abuse Ages 6-12*

MORE SERVICES: Drug and alcohol abuse Ages 13-21*

Parent behavior training (e.g. Triple P)

MORE SERVICES: Parent behavior training (e.g. Triple P) Ages 2-5*

MORE SERVICES: Parent behavior training (e.g. Triple P) Ages 6-12*

MORE SERVICES: Parent behavior training (e.g. Triple P) Ages 13-21*

Access questions:

How long does it take for a new patient to be seen for the first time?*

Same day
Less than 7 days
Less than 30 days
30-60 days
More than 60 days

How many additional patients with immediate care needs, (i.e. suicidal patients) could you see a week?*

If a patient needs to be seen once or twice weekly for 1-2 months how many of those treatment courses could you provide?*

Additional Comments/Questions

Hidden

subsid

Driscoll Health Practice Qualification Review

In the last 3 months, how many children in each (diagnosis x age) group have you evaluated or treated

On a scale of 1 to 5, how well-trained or experienced do you rate yourself in each (diagnosis x age) group.

In what areas have you received specialized, supervised training as part of an internship or certification? CEUs without supervised practice do not count here.

Please identify which (age x diagnosis) groups you would be willing to provide more services or receive more training to qualify yourself to provide those services.

Access questions:

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