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Qualification Screener

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Instructions: There are 20 questions in this qualification screener; it will take approx. 3-7 minutes for you to complete. Please provide the participant demographics below, click NEXT at bottom of screen, respond to all 20 questions and click SUBMIT once complete. Once submitted, responses cannot be changed. Someone will review your selections and get back to you to schedule your interview if you qualify.

Name of Participant: *

Parent/Legal Guardian: (if minor participant)

Age of Participant: *

Date of birth: *

Gender: *

Male
Female
Transgender/Other

Email

(Parent/Legal Guardian if minor participant):

Phone Number *

(Parent/Legal Guardian if minor participant):

Race/ Ethnicity *

Preferred time of contact *

Day
Evening
Any

1. Do you have access to a mobile phone capable of downloading mobile apps? *

Yes
No

2. Do you have access to a laptop or computer with WIFI and webcam? *

Yes
No

2A. Are you willing to meet for an in-person focus group interview? *

Yes
No

3. Are you willing to keep all information discussed in your interview confidential? *

Yes
No

4. Do you consent to being recorded during your interview? (All recordings are for internal company use only) *

Yes
No

5. Select which BEST applies. The location I primarily live in is: *

Rural
City

6. Select which BEST applies. The location I primarily work/attend school in is: *

Rural
City
I do not work/attend school

7. Do any of these describe you? Please select ALL that apply.

Adolescent (12-17yrs)

7. Do any of these describe you? Please select ALL that apply.

Adult (18-55yrs)

7. Do any of these describe you? Please select ALL that apply.

Senior (64-75yrs)

7. Do any of these describe you? Please select ALL that apply.

Homeless

7. Do any of these describe you? Please select ALL that apply.

Veteran

7. Do any of these describe you? Please select ALL that apply.

Parent

Parent *

w/ child <10yrs
w/ child >11-17yrs
Neither

7. Do any of these describe you? Please select ALL that apply.

Primary Care Provider: MD

7. Do any of these describe you? Please select ALL that apply.

Pediatric Doctor: MD

7. Do any of these describe you? Please select ALL that apply.

Neurologist: MD

7. Do any of these describe you? Please select ALL that apply.

Assisted Living/Nursing Home/ Personal Care Home: Director, Therapist/Social Worker, MD, RN, or Staff

7. Do any of these describe you? Please select ALL that apply.

Emergency Department: MD, RN, PA, or NP

Emergency Department: Social Services/Therapist

Emergency Department: Social Services/Therapist

7. Do any of these describe you? Please select ALL that apply.

Joint Commission Staff: Behavioral Health Department

7. Do any of these describe you? Please select ALL that apply.

Lawyer: Behavioral Healthcare

7. Do any of these describe you? Please select ALL that apply.

Work in the Education System as a:

Work in the Education System as a: *

Counselor
Principal
None of the above

Counselor/Principal *

Private/Charter School
Public School
College/University
None of the above

7. Do any of these describe you? Please select ALL that apply.

Work in the Legal/Law Enforcement System as a:

Work in the Legal/Law Enforcement System as a: *

Police Officer
Probate Court Judge/Staff
Jail Captain/ Staff
RYDC Director/Staff
None of the above

7. Do any of these describe you? Please select ALL that apply.

In DFCS System/Network as a:

In DFCS System/Network as a: *

Adolescent in foster care/group home (12-16yrs)
DFCS Case Manager
DFCS Group Home/Foster Care Staff
None of the above

7. Do any of these describe you? Please select ALL that apply.

Work in Crisis as a:

Work in Crisis as a: *

Crisis Assessor/Therapist/Social Worker
Suicide Hotline Worker
Director of Crisis Assessment Team
Placement Specialists
None of the above

7. Do any of these describe you? Please select ALL that apply.

Work in Inpatient Behavioral Health/Detox Facility as a:

Work in Inpatient Behavioral Health/Detox Facility as a: *

Intake RN/MD/NP/PA
Intake Staff
Intake Director
Social Services- Therapist/Social Worker
Social Services- Director
None of the above

7. Do any of these describe you? Please select ALL that apply.

Work in Outpatient Mental Health/Substance Use as a:

Work in Outpatient Mental Health/Substance Use as a: *

Therapist/Social Worker
Director
Psychiatrists/NP/PA
None of the above

7. Do any of these describe you? Please select ALL that apply.

Work in Transportation as a:

Work in Transportation as a: *

Private EMS Company OWNER
EMT/Paramedic
Uber/Lyft Driver
None of the above

7. Do any of these describe you? Please select ALL that apply.

None of the above describe me

8. Do you CURRENTLY work for any of the following types of providers? Please select ALL that apply. *

Georgia Crisis and Access Line
DBHDD CSU-Inpatient
DBHDD CSB-Outpatient
Veterans Administration
Crisis/Detox Facility-Private
Crisis/Detox Facility-Medicaid
Residential/Rehab Program
Private Practice-Behavioral Health
Community Provider- Behavioral Health
None of the Above

9. Have you done any of the following in the last year? Please select ALL that apply. *

Sought treatment for yourself at an inpatient crisis/detox facility
Sought treatment for yourself in an outpatient mental health/substance use setting
None of the above apply

9A. Was this process? *

Easy
Difficult
Neither

10. Have you done any of the following in the last year? Please select ALL that apply. *

Received treatment for yourself at an inpatient crisis/detox facility
Received treatment for yourself in an outpatient mental health/substance use setting
None of the above apply

11. Have you done any of the following in the last 7 months? Please select ALL that apply. *

Sought treatment for someone else at an inpatient crisis/detox facility
Sought treatment for someone else in an outpatient mental health/substance use setting
None of the above apply

11A. Was this process? *

Easy
Difficult
Neither

12. Have you tried to seek any mental health/substance use treatment for yourself or someone else without insurance in the last 7 months? *

Yes
No

13. Have you tried to seek any mental health/substance use treatment for yourself or someone with SSI Disability Medicaid in the last 7 months? *

Yes
No

14. Have you tried to seek any mental health/substance use treatment for yourself or someone else with severe behavioral problems, developmental disability, and/or medical concerns in the last 7 months? *

Yes
No

15. MD/NP/PA ONLY: Have you worked as the on call provider receiving calls for staffing/accepting patients to a crisis/detox facility in the last month? *

Yes
No
Not Applicable

16. RN/NP/PA ONLY: Have you had to complete a Nurse to Nurse to accept a patient to a crisis/detox facility in the last month? *

Yes
No
Not Applicable

17. Have you done any of the following in the last 7 months? Please select ALL that apply. *

Had a crisis assessment completed for yourself or someone else
Had to wait longer than 1hr to have a crisis assessment completed for yourself or someone else
Parent/ Legal Guardians ONLY: Required to leave work to pick up a child from school to get a crisis assessment completed
None of the above apply

18. Crisis Workers Only: Have you completed a crisis assessment via zoom or in-person in the last month? *

Yes
No
Not Applicable

19. Have you transported a patient in the following capacity in the last year? Please select ALL that apply. *

From home/community to a Crisis/Detox facility
From an Crisis/Detox facility to home/community
From Home/Community to Emergency Room for a mental health/substance use concern
From Emergency Room to a Crisis/Detox facility
None of the above apply

20. Preferred payment method? *

Cash App
Zelle
Apple Pay
Virtual Visa Gift Card (can only be used online)
Visa Gift Card by mail (allow up to 10 business days to receive)
Cash/Visa Gift Card (In-Person Only Interviews)