Today's Date
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Now M-D-Y H:M
Full Name
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Preferred e-mail address
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Preferred phone number
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Organization / Agency Name
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Practice e-mail address
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Practice street address
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Practice city
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Practice zip code
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County in which your practice is located
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Gender
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Age (please enter in number of years)
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Race (please select all that apply)
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Other race or ethnicity not listed above:
Ethnicity
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Hispanic, Latino/a/x, or Spanish origin
Non-Hispanic or Non-Latino/a/x
Prefer not to say
What is your highest or most advanced degree?
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None
High School Diploma or GED
Some college
Associate's Degree
Bachelor's Degree
Master's Degree
Doctoral Degree
Specialist Degree
Other
What is your primary mental health specialty or discipline?
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Please note your primary mental health specialty.
What is your mental health licensure status?
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Student (e.g., trainee, intern)
Post-masters/Post-doctorate (e.g., provisionally licensed
Indiana Licensed MH Provider (e.g., LCSW, LMFT, LPC, Licensed Psychologist)
Other (please specify below)
Please specify your licensure status.
What is your current employment setting? (check all that apply)
Specify current employment setting
How long have you been with your current employer? Please enter years in whole numbers.
Approximately what is the size of your practice or the site where you deliver services (total number of employees)?
0-9 persons employed
10-49 persons employed
50-99 persons employed
100-249 persons employed
250+ persons employed
What percentage of persons employed at your practice or site are non-clinical staff?
What is/are your current role(s)?
Please specify your current role:
Do you currently receive or provide supervision?
I receive supervision
I provide supervision
N/A I do not receive or provide supervision
Do you receive live supervision (i.e., your supervisor directly observes your sessions) or review video or audio recordings of your sessions with your supervisor in supervision?
Yes
No
Do you provide live supervision (i.e., directly observe your supervisees' sessions) or review video or audio recordings of your supervisees' sessions in supervision?
Yes
No
For how many years have you worked in the behavioral health field?
For how many years have you worked in the substance use/addictions field?
Do you have a certification (in addiction or substance abuse counseling)?
Yes
No
Please specify the certification that you have.
Approximately how many patients do you have on your current caseload?
What percentage of the patients on your current caseload have substance use disorder(s)?
What percentage of your current work is with adolescents?
What percentage of your current work is with adults?
Do you expect to be working with any adolescents with substance use disorders over the next six months?
Yes
No
What proportion of your patients with substance use are struggling with alcohol?
What proportion of your patients with substance use are struggling with nicotine?
What proportion of your patients with substance use are struggling with cannabis?
What proportion of your patients with substance use are struggling with inhalants?
What proportion of your patients with substance use are struggling with methamphetamine?
What proportion of your patients with substance use are struggling with cocaine?
What proportion of your patients with substance use are struggling with sedatives/hypnotics/anxiolytics?
What proportion of your patients with substance use are struggling with opioids?
What proportion of your patients with substance use are struggling with hallucinogens?
What proportion of your patients with substance use are struggling with prescription or over the counter medicines?
Do you have patients that struggle with another substance not mentioned above?
Yes No
Specify the other substance.
What proportion of your patients with substance use are struggling with this other substance?
Are you familiar with contingency management?
Yes
No
Do you have prior experience using contingency management?
Yes
No
How many patients have you used contingency management with in the past 3 months?
Have you attended or received prior training in contingency management?
Yes
No
If so, please specify the type of training (check all that apply).
Please specify the type of training you received.
Do you have prior training or experience with other evidence-based substance use treatments?
Yes
No
Please specify what other evidence-based substance use treatment(s) you have experience with.
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