Mind Over Mood Initiative Partnership Determination Survey_Revised

Dear Mind over Mood Interested Clinicians,

Thank you for your interest in partnering with early childhood home visitation programs through our Mind over Mood Initiative to help us link parents to psychotherapy. Please tell us more about your psychotherapy practice! We are eager to learn more about you and invite you to our two-part training for perinatal/infant mental health therapists. Thank you for taking the time to complete this survey. You will receive a response with training registration information from Claudia Liloy or Jen Vendetti. If you have specific questions, email Jen at Jvendetti@uchc.edu or call 860-679-3703.

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* 1. Practice Contact Information

Name *

Credentials *

Address *

Address 2

City/Town *

ZIP/Postal Code *

Email Address *

Phone *

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* 2. If applicable, what is your fax number?

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* 3. If applicable, what is the name of the group practice you are part of?

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* 4. Are you an independent practice clinician in Connecticut?

Yes, full time private/small independent group practice

Yes, part time private/small independent group practice

No, I'm in the planning stages

No, I work for an agency-based practice

Other (please specify)

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* 5. Are you credentialed as a Husky behavioral health provider?

Yes, and I've billed Husky successfully

Yes, but I haven't billed Husky yet

No, I am currently in the process

No, not yet

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* 6. Have you ever provided psychotherapy in families' homes?

Yes, I have past and current home-based tx experience and training

Yes, I have past home-based tx experience and training

Yes, but limited experience providing services in the home

No, but I am willing to expand my practice to include home-based tx

Other (please specify)

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* 7. Do you provide psychotherapy in languages other than English?

Yes

Specify other practicing language(s)

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* 8. Tell us about your experience working with pregnant and postpartum mothers experiencing depression or anxiety?

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* 9. What is your experience working with early childhood home visitation?

I have worked in home-based prevention services

I have worked in home-based clinical services

I have worked in child welfare services

I have worked in early intervention services

I have worked in collaboration with home visitation services

I have no experience working with home-based early childhood services

Other (please specify)

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* 10. What is your training and experience treating Perinatal Mood and Anxiety Disorders

I have formal training and experience in treating PMADs

I have formal training but limited experience in treating PMADs

Limited training and experience treating these disorders

My practice specializations include:

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* 11. What is your training and experience treating Perinatal Mood and Anxiety Disorders

I have formal training and experience in treating PMADs

I have formal training but limited experience in treating PMADs

Limited training and experience treating these disorders

My practice specializations include:

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* 12. What is your training and experience in dyadic work?

I have formal training and experience working with parents and infants/young children

I do not have formal training but I have worked with parent-infant dyads

I am hoping to learn more about attachment-based practice/working with mother-child dyads

Other (please specify)

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* 13. What is your hope and expectation for client referrals?

I hope/expect a steady stream of referrals from the home visiting site I am partnered with

I hope/expect one or two active cases at a time from my partnered home visiting site

I have no specific hope/expectation for referrals but want to be in a partnering role with my local home visiting program

I have no client openings at this time

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* 14. How would you describe your referral availability?

I often have multiple openings

I often have one or two available openings

I am often at capacity and have a waiting list

I am often full during the day but have evening and weekend availability

I only offer my practice evenings and weekends

Other (please specify)

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* 15. Are you willing to receive referrals (when you have availability) directly via encrypted email or fax and contact the referred mom/parent directly to set up an Intake/Assessment? (the Home Visitor has already paved the way for the mom/parent to receive your call)

Yes

I'm not comfortable contacting the referred parent directly to set up an Intake/Assessment

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* 16. Are you willing to complete a brief Treatment Summary Form (no client identifiers)?

Yes

I need to learn more