Microsoft Forms

Facilities Information Form

Forms for Facilities and Rehabs
What is the name of the facility?*
Where is the facility located (full address)?*

Street Address

Street Address Line 2

CityState

Zip Code
Where is the facility located?
Country*
Street Address*
Street Address Line 2
City*
State*
Zip Code*
Country Hidden - Text Field
State Hidden - Text Field
Country Hidden - drop down
State Hidden - drop down
What is the phone number for the facility?*

Area CodePhone Number
What is the website for the facility?
Name of contact/ Liaison at the facility:*
What is the contact's Phone Number?*

Area CodePhone Number
What is the contacts Email Address?*
example@example.com
Are there other locations?*

YesNo
If Yes, Please list other locations?*
Who is the Clinical Director at the facility?*
What is the Clinical Director's Phone Number?*

Area CodePhone Number
What is the Clinical Director's Email Address?*
example@example.com
Do we have another other contacts at the Facility?*

YesNo
If Yes, What is their name?
If Yes, What is their Phone number?

Area CodePhone Number
If Yes, What is their Email Address?
example@example.com
What types of treatment programs do you offer?*

Aftercare ProgramsDay TreatmentDetoxDual Diagnosis TreatmentFamily Therapy ProgramsHolistic ProgramsInpatientIntensive Outpatient Programs (IOP)Medication-Assisted Treatment (MAT)OutpatientPartial HospitalizationPsychiatry / Medication ManagementResidential TreatmentSober Living HomesTherapeutic Communities (TC)Other: Please limit your response to 80 characters. Longer responses cannot be processed.
Which specific conditions do you treat?*

Anger Management IssuesAnxiety DisordersBehavioral AddictionsChronic Pain ManagementDevelopmental DisordersDual DiagnosisEating DisordersGrief and LossMental Health DisordersMood DisordersObsessive-Compulsive Disorder (OCD)Personality DisordersPostpartum Depression and AnxietyRelationship and Family IssuesSelf-Harm BehaviorsSex AddictionSubstance AbuseTrauma and PTSDOther: Please limit your response to 80 characters. Longer responses cannot be processed.
What types of specialized programs do you offer?*

Adult ProgramsAthlete Recovery ProgramsCourt-Ordered/Legal ProgramsFamily ProgramsFirst Responders ProgramsFaith-Based ProgramsHealthcare Professionals ProgramsLGBTQ+ ProgramsMen's ProgramsMilitary Family ProgramsPrograms for Pregnant and Postpartum WomenPrograms for Seniors/ElderlyPrograms for TeensPrograms for Individuals with DisabilitiesVeterans ProgramsWomen's ProgramsPrograms for Executives and ProfessionalsCollege Student ProgramsOther: Please limit your response to 80 characters. Longer responses cannot be processed.
Are you Shabbat Friendly?*

YesNo
Are you Kosher Friendly?*

YesNo
Where do you get Kosher food from and how?
What accreditations does your facility have *

Accreditation Association for Ambulatory Health Care (AAAHC)Behavioral Health Center of Excellence (BHCOE)CARF (Commission on Accreditation of Rehabilitation Facilities)Council for Higher Education Accreditation (CHEA)Council on Accreditation (COA)Joint CommissionNational Association of Addiction Treatment Providers (NAATP) MembershipNational Committee for Quality Assurance (NCQA)State Licensure and Regulatory Body AccreditationSubstance Abuse and Mental Health Services Administration (SAMHSA) CertificationInternational Organization for Standardization (ISO) CertificationOther: Please limit your response to 80 characters. Longer responses cannot be processed.
Are your staff members licensed and certified in their respective fields?*

YesNoOther
Please explain*
What types of therapies do you offer?*

Acceptance and Commitment Therapy (ACT)Art TherapyCognitive-Behavioral Therapy (CBT)Dialectical Behavior Therapy (DBT)Exposure TherapyFamily TherapyGroup TherapyHolistic Therapies (e.g., yoga, meditation)Interpersonal Therapy (IPT)Mindfulness-Based TherapyMotivational InterviewingNarrative TherapyPlay TherapyPsychodynamic TherapySolution-Focused Brief Therapy (SFBT)Trauma-Informed CareExpressive Arts TherapyOther: Please limit your response to 80 characters. Longer responses cannot be processed.
Do you offer holistic or alternative therapies?*

YesNo
If Yes, Which holistic or alternative therapies do you offer?*

AcupunctureAromatherapyArt TherapyAyurvedic TherapyBiofeedbackBreathworkChiropractic CareEnergy Healing (e.g., Reiki)Guided ImageryHerbal TherapyHolistic NutritionHypnotherapyMassage TherapyMeditationSound TherapyTai ChiTherapeutic TouchYogaOther: Please limit your response to 80 characters. Longer responses cannot be processed.
Are there any additional services provided?*

YesNo
What additional services do you provide?*

Aftercare PlanningCase ManagementCrisis InterventionEducational SupportFamily Support ServicesHealth and Wellness ProgramsHolistic Services (e.g., nutrition counseling)Legal AssistanceLife Skills TrainingMental Health CounselingMedication ManagementRecreational TherapyRelapse Prevention ProgramsSupport GroupsVocational Training
Please provide information about your clinical staff (e.g., number of staff, qualifications,specialties)?*
Do you have on-site medical professionals (e.g., doctors, nurses)?*

YesNo
What amenities does your facility offer?*

GymHorseback RidingKitchen FacilitiesMeditation RoomsMusic Therapy RoomsOutdoor Spaces/GardensPoolPrivate RoomsQuiet AreasRecreational ActivitiesSauna/Steam RoomsSports Facilities (e.g., basketball, volleyball courts)Therapy RoomsWi-Fi AccessOther: Please limit your response to 80 characters. Longer responses cannot be processed.
What is the living arrangement like at your facilities?*

Group HousingPrivate RoomsShared RoomsTransitional HousingWellness SuitesOther: Please limit your response to 80 characters. Longer responses cannot be processed.
What is the process for admission?*
Is there a discount for Amudim?*

YesNo
If Yes, What is the discount price?
Is there a waiting list for admission?*

YesNo
What is the average length of stay for each type of program?*
What other forms of payment do you accept?*

Cash PaymentCredit/Debit CardsGovernment Assistance ProgramsInsurancePayment PlansPrivate PayScholarshipsSliding Scale FeesThird-Party Funding (e.g., grants)Veteran BenefitsHealth Savings Accounts (HSAs)Flexible Spending Accounts (FSAs)Other: Please limit your response to 80 characters. Longer responses cannot be processed.
Do you offer financial assistance or payment plans?*

YesNo
What role do families play in the treatment process?*
Do you offer family therapy or family support groups?*

YesNo
What types of aftercare or follow-up services do you provide?*
Do you have partnerships with other local resources for ongoing support?*

YesNo
If Yes, please explain:*
What languages are spoken by your staff?*

ArabicChinese (Mandarin and Cantonese)EnglishFrenchHebrewHindiItalianJapaneseKoreanPortugueseRussianSpanishTagalogVietnamese
Is your facility accessible for individuals with disabilities?*

YesNo
What age groups do you serve?*

Children (ages 5-11)Adolescents (ages 12-17)Young Adults (ages 18-25)Adults (ages 18-64)Seniors (ages 65 and older)
What specific populations do you specialize in?*

Gender-Specific ProgramsLGBTQ+ IndividualsMilitary VeteransPregnant and Postpartum WomenReligious AffiliationsSeniors/ElderlyTeens/AdolescentsTrauma SurvivorsFirst RespondersIndividuals with DisabilitiesProfessionals/ExecutivesOther: Please limit your response to 80 characters. Longer responses cannot be processed.
What types of treatment programs do you offer? (Select all that apply)

Detox ServicesResidential Treatment Center (RTC)Partial Hospitalization Program (PHP)Psychiatry / Medication ManagementIntensive Outpatient Program (IOP)Outpatient Therapy
Any other information that you would like us to know about your facility:
Should be Empty:

Facilities Information Form

Where is the facility located?