Organizational Information

Organization Name *

Contact Name *

First

Last

Organization Website / URL

Where patients can acquire more information

Contact Email *

Confirm Email

Street Address of Primary Organization *

Address Line 1

Address Line 2

City

State

Zip Code

PCBH Characteristics

In your Clinics that Have a BHC, What is the Usual Ratio Of BHC To PCP?

1:1 - 1:2
1:3 - 1:4
1:5 - 1:6
1:7 - 1:8
1:9 - 1:10
1:11 +

Which Age Groups Do Your BHCs Engage With? (Check All That Apply)

Younger Pediatric (0-11)
Older Pediatric (12-18)
Adults
Older Adults (65+)
Our BHCs Vary In Terms Of Patient Ages Seen

Are There Certain Types Of Problems Or Problem Severities/Complexities That Your BHCs Do NOT Engage With?

If no, Please Explain:

How Long Are The Visits On BHC Schedule Templates In Your Organization? (Check All That Apply)

15 Minutes
30 Minutes
45 Minutes
60 Minutes

Do Your BHCs Typically See Patients For a Visit on the Same Day They Were Referred?

Do Your BHCs Regularly Inform/Educate Team Members About Behavior Change Topics?

Which Statement Best Applies to BHCs In Your Organization?

BHCs Have Their Own Office And Mostly See Patients There
BHCs Have Their Own Office But Mostly See Patients In An Exam Room
BHCs Have A Workstation in a Team Pod And See Patients in an Exam Room
Other

Please Elaborate

If Your Organization has a Goal For BHC Visits Per Day, What is the Goal?

0-4
5-6
7-8
9-10
11-12
13+
We Don't have a Goal

Do BHCs In Your Organization Regularly Look for Ways to Extend PCPs?

Yes
No
Not Sure

Services & Sites

Which of the below best describes your organization?

FQHC/CHC
Healthcare for the Homeless
Private Non-Profit
DoD
Rural Health Clinic
Private For-Profit
VA
Other

Please Provide a brief description:

Types of Primary Care Your Organization Offers (Check all that apply)

Family Medicine
Internal Medicine
Pediatrics
Geriatric Medicine

Number of Primary Care Clinics Your Organization Has

1-3
4-10
11-20
21-30
31-40
40+

Number of Clinics With At Least 1 BHC

1-3
4-10
11-20
21-30
31-40
40+

If you would like to have multiple clinics on the PCBH Map, please list them here (no need to re-submit entire form):

Please Include: Clinic Name, Address, Contact information, Services Offered

Additional Information

Type Of Integrated Care Or Co-Located Services Offered By Your Organization

PCBH (embedded clinician, real-time access)
Collaborative Care (care management & consulting psychiatry)
SBIRT (substance abuse brief treatment)
Medication Assisted Treatment (opioid)
Specialty Psychotherapy (referral-based therapy)
Consulting Psychiatry (psychiatry supporting primary care)

Availability

Offered at All Sites
Offered at Some Sites
Not Offered

Estimate The Number Of Unique Patients Served Annually by Your Organization

Is Your Organization Accepting New Patients?

Is Your Organization a Medical Residency Site?

If Yes, Approximately what percent of your organization’s visits are done by medical residents?

1-10
11-25
26-50
51-75
76-100

Does Your Organization Train Behavioral Health Learners (e.g., Students, Interns, Post-Docs)?”

If Yes, How Many Learners Do You Train Each Year?”

1-3
4-6
7-10
11-15
16+

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PCBH Characteristics

Services & Sites

Additional Information

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