CMHC Survey

Mental Health Center/Program Survey

For the purposes of this survey, please use the following definitions:

Deaf - An individual who has a permanent hearing loss and is not able to understand or discriminate speech sounds in verbal communication, with or without amplification (hearing aids) and relies primarily on visual forms of communication (such as sign language or lipreading)

Hard of Hearing - An individual who has a permanent hearing impairment which is severe enough to necessitate the use of amplification devices to understand or discriminate speech sounds in verbal communication, and relies primarily of auditory/oral forms of communication.

	Name: Address: City: State:Zip:
	Geographic area served by this payor (county, region, etc.):
	Do you have staff employed by your Center (not contractual) who have been trained to work with persons who are deaf or hard of hearing? Yes No If Yes, How Many
	Do you have staff members who are themselves deaf or hard of hearing? Yes No If Yes, How Many
	How many persons who are deaf or hard of hearing received services from your program within the past twelve months?

Ages	Deaf	Hard of Hearing	Other Hearing Problem*
0-17
18-64
65 and older

* Includes central processing deficits, factious disorders, malingering, etc.

What method do you have for tracking deaf or hard of hearing consumers?

Rank the following services, in terms of those provided most frequently to deaf/hard of hearing consumers in your program within the last 12 months. (#1 = most used, #15 least used; X = this service not provided to Deaf or Hard of Hearing consumers; N/A = service not provided by your program)

Service	Rank	Service	Rank
Intake		Assessment (non-MD)
Crisis Management		Individual Therapy
Inpatient Services		Family Therapy
Residential Services		Case Management
Partial Hospitalization		MD Assessment
Independent Living Skills		Case Consultation
Psychological Testing		School Based Services
Therapeutic Foster Care		Intensive In-Home Services
Supported Employment		Other:

Which of the following auxiliary aids do you have available "in house" or by written contract to provide access to deaf and hard of hearing consumers?

Auxiliary Aid	In House	Contract	Number of times used in last year (approx)
Qualified Interpreters
Note Takers
Written Transcription Devices (C-CAP or X-Scribe)
Telecommunication Devices for the Deaf (TDD/TTY)
Telephone Handset Amplifiers
Hearing Aid compatible telephones
Assistive Listening Systems
Assistive Listening Devices (individual)
Closed captioned televisions
Visual Alarms/ other alerting devices
Other

How do you assess the accommodations necessary for a deaf or hard of hearing individual to access your services?
(check all that apply)
We have an established policy.
We ask the consumer.
We have outside assessors.
We have designated staff to assess needs.
We use another method (specify)

How do you assess the qualifications of sign language interpreters? (check all that apply)
We have an established contract with an agency.
We ask the consumer if the interpreter is acceptable.
We have outside assessors.
We have designated staff to assess qualifications.
We use only certified/licensed interpreters.
We use another method (specify)

Does your Center/Program provide emergency telephone (hotline) intervention services. Yes No

If Yes, how are these services accessible to Deaf or Hard of Hearing consumers?
Our lines have a TTY/TDD available.
We have a dedicated TTY/TDD line.
We use the state dual-party relay service.
We use another method (specify)

Does your center conduct outreach/community information program to inform the public of your services?Yes No

If Yes, how are these services accessible to Deaf or Hard of Hearing consumers?
We provide interpreters/ALD's for all functions.
We provide interpreters/ALD's when requested.
We encourage deaf/hard of hearing consumers to bring their own interpreters or ALD's.
We use another method (specify)

Do you use videotapes or films in the provision of services?Yes No

If Yes, how are these services accessible to Deaf or Hard of Hearing consumers?
We provide interpreters/ALD's for all movies and videotapes.
We purchase only captioned movies/videotapes and all our TV's are closed captioned.
We provide interpreters/ALD's when requested.
We encourage deaf/hard of hearing consumers to bring their own interpreters or ALD's.
We use another method (specify)

Person completing the survey:
Name:
Title:
E-Mail