Health New England, How Can We Help?

Could you spare two minutes to help us update our records? All you have to do is answer the two simple questions below. This information will help us evaluate doctors' responses when patients call seeking care for a non-life threatening behavioral health emergency.

We appreciate your help!

To complete the Survey On-line, fill in the information below, then click SUBMIT when finished. Or, if you would prefer, you may print this page and fax the completed questionnaire to 413-233-2751.

What is your practice's usual response when a patient calls seeking care for a non-life threatening behavioral health emergency? For purposes of this evaluation, a non-life threatening behavioral health emergency is described as "a condition that requires rapid intervention to prevent deterioration of the patient's state of mind which, if left untreated, could jeopardize the patient's safety."

1. During business hours:

Patient provided appointment.
If so, within:	One to six hours of call Next day
Patient told to seek care through BH crisis team.
If so, is patient provided the name and phone number of the crisis team closest to his or her location?		Yes No
Other, please specify:

2. After hours and on weekends:

	Answering Service instructs patients to seek care through ER or BH crisis team.
	Answering Service notifies PCP or BH provider.
	If so, once notified of a patient call, on average, how quickly is the call returned?
	Within:	15 minutes 30 minutes 60 minutes Other
	Answering machine provides instructions.
	If so, please provide message text:
	Other, please specify:

Practice Name or PCP Name:
Street Address:

City:
State:		Zip:

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