Healthcare Resource Assessment - Behavioral Health (Responses)
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TimestampEmail Address
1. Name of Behavioral Health Organization:
2. Location of facilities (check all that apply):
3. Jurisdictions served (select all that apply):
4. 24/7 primary organization contact - Name:
5. 24/7 primary organization contact - Phone:
6. 24/7 primary organization contact - E-mail:
7. 24/7 alternate organization contact - Name:
8. 24/7 alternate agency contact - Phone:
9. 24/7 alternate agency contact - E-mail:
10. Which type(s) of services does your organization provide (select all that apply)?
11. If your organization provides residential services, please provide the total number of residential beds within your organization:
12. Does your organization provide services to (select all that apply):
13. Does your organization provide services to the forensic population, including violent offenders?
14. Does your organization provide substance abuse services?
15. Does your organization provide detoxification services?
16. Does your agency provide opioid replacement therapy services (e.g., methadone, suboxone, etc)?
17. Does your agency provide walk-in crisis services?
18. Does your agency have access to on-site pharmaceuticals/ have an on-site pharmacy?
19. Please upload a spread sheet of your transportation resources to https://drive.google.com/drive/folders/1EkQ7xHYQMnEC1NilN1ODlXDlfdF9SUnE?usp=sharing. Rename your document with your organization name in the title. If you are unable to access the Google Drive, please e-mail your spread sheet to SWCHCC@gmail.com. Please include the following in your spreadsheet for each transportation resource: type of vehicle, capacity, if it is ADA compliant, and the total number of staff trained to drive the vehicle
20. Is your agency currently part of the Colorado Crisis Education and Response Network (CoCERN)?
21. How many disaster behavioral health responders does your agency currently have trained and ready to deploy?
22. Please list any disaster response/support related MOUs that your organization currently has in place:
23. Please identify which communication modalities your facility currently supports (select all that apply):
24. Please select all radio capabilities currently available within your facility:
25. Number of portable or mobile radios programmed to be interoperable within the Southwest region:
26. Do you have staff that can administer vaccines to adults?
27. Do you have staff that can administer vaccines to children?
28. Does your facility have the ability to be a durable medical equipment charging location for members of the public? *Please note that this would be coordinated through support partners such as emergency management and/or emergency support function 8
29. Please select which generator capabilities your facility currently supports (select all that apply):
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