TREAT ME Initial Interest Survey
1.
Please provide your credentials (MD, DO, PA, NP, PhD, RN, other)
2.
Are you planning to attend the entire collaborative or one or more individual blocks?
Entire collaborative
One or more individual blocks
3.
Are you enrolling as a member of a practice team?
Yes
No
4.
Please Name Team Lead:
5.
Practice Scope:
Psychiatry
Pediatrics
Behavioral Health
Family Medicine
Addiction Medicine
APP
Other:
6.
Do you use a validated tool such as BSTAD, S2BI, or CRAFFT to screen for adolescent substance use in your practice?
Yes
No
7.
Do you or does anyone in your practice provide buprenorphine to adolescents to treat OUD?
Yes
No
8.
Do you offer medication for nicotine use disorder to adolescents?
Yes
No
9.
Do you offer medication to treat alcohol use disorder for adolescents?
Yes
No
10.
Do you have embedded behavioral health in your practice?
Yes
No
