| TREATING
TEENS |
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Adolescent Treatment Provider Mail/Fax Survey
1. Facility
Name: _________________________________________________
2. Facility
Location:_______________________________________________
3. Other Branches:________________________________________________________
4. Year Established:______________________________________________
5. What levels
of treatment does your program provide? (Check all that apply and
briefly describe services and length of time)
__Detoxification
__Residential
__Partial Hospitalization
__Outpatient
__Early Intervention
__Aftercare
__Halfway House
__Sober Living
__After school
Description:
Please answer
the remainder of the questions for each adolescent level of care
your program provides.
6. How do you
define adolescent? _____________________________
7. Does the
program offer special programming based on gender, age, ethnicity,
criminal involvement, or any other issue? If yes, please describe.
8. What types
of group sessions are offered (such as Marijuana Addiction, Eating
Disorders, Gay and Lesbian, Anger Management, Relapse Prevention)?
9. Do you offer
individual therapy? Yes No
10. Are you Licensed by:
___State
___County
___Other ____________________________
11. Types of
Licences:
___Youth treatment facility
___Halfway house
___School
___Other___________________________
12. Accredited
by:
___Joint Commission on Accreditation of Healthcare Organizations
(JCAHO)
___Rehabilitation Accreditation Commission (CARF)
___Other____________________________________
13. Is there
one primary treatment modality or philosophy that guides your program?
___Twelve
Step
___Cognitive Behavioral Therapy
___Motivational Enhancement Therapy
___Multisystemic Therapy
___Multidimensional Family Therapy
___Other _______________________________
___Combination of modalities/philosophies; please explain
14. What is
your smoking policy? Is it different for staff (and adults, if applicable)?
15. What is
your policy for substance use by clients in your program? How strictly
is the policy enforced?
16. Do you have a waiting list to enter your program? If no, can
clients access your program on demand?
17. How are
adolescents typically referred to your program?
18. Can adolescents
access services at the facility without parental consent?
Yes No
Program Statistics
19. Number of
adolescent treatment slots__________________________________
20. What is
the average occupancy rate? ________________________________
21. What is
the average length of stay?_________________________________
22. What is
the ratio of staff to patients? __________________________________
23. What is
the rate per day/month? _________________________________
24. How do people
typically pay for services?
What forms of
payment are accepted: (check all that apply)
___Medicare
___Medicaid
___Private Insurance
___Public Assistance
___Sliding Fee Scale
___Other Assistance
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Programs
