2009 BEHAVIORAL HEALTH WORKGROUP ORGANIZATIONAL RESOURCES ASSESSMENT

Name:                                    

Title:                                        

Email Address:            

Telephone:    

Organization:                            

Mailing Address:

City:    

State:    

ZIP:                  

Physical Location Address:
City:            State: 
Zip:     

Counties Served/Catchment Area:


Your Main Job Category:


Your Highest Degree:


How long have you worked in mental health? 
(Please give a number in whole numbers: 0, 1, 2, etc. Round to the nearest whole number.)

How long have you worked in primary care?
(Please give a number in whole numbers: 0, 1, 2, etc. Round to the nearest whole number.)

How long have you worked in some sort of integrated Primary Care and Mental Health model? 
(Please give a number in whole numbers: 0, 1, 2, etc. Round to the nearest whole number.)

Please use the following table to answer the questions below:
  1  2  3  4  5
  minimal collaboration
basic collaboration from a distance 
 basic collaboration on site
 close collaboration in a partly integrated system
 close collaboration in a fully integrated system
 "Nobody knows my name."  

"Who are you?"
 "I help your patients."

 "You help my patients but not me."
  "I am your consultant."

"You help me as well as my patients."

  "We are a team in the care of our patients."
  "Together, we also teach others how to be a team in care of patients and design of the care system."
  Traditional referral between specialties model.
  Traditional referral between specialties model.
  Co-location model
Organization integration or "primary care mental health" model 
Organization integration or "primary care mental health" model 


What level of integrated collaboration currently exists in your organization?  (Use the scale above to select ONLY ONE answer.)
    1                2            3             4             5

What level of integration does your organization seek?
(Use the scale above to select ONLY ONE answer.)
    1                 2           3              4            5

What are the most challenging barriers to integration of behavioral health at your organization? (Please list your top 3.)


Which of the two subgroups will you join?
(You may join only one as the groups will be meeting at the same time.)
  Clinical subgroup            Financial subgroup

What outcome/s do you expect to achieve through your participation in the Behavioral Health Workgroup? (Please list, be clear and concise.)



If you have any questions, please contact Israel Garcia at 919.297.0066.

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