age_group
(
nullable: true, editable: true, defaultValue: null, length: 255, alias: What is your age?, type: esriFieldTypeString
, Coded Values:
[0_15: 0-15 years old]
, [16_25: 16-25 years old]
, [26_59: 26-59 years old]
, ...2 more...
)
assigned_sex
(
nullable: true, editable: true, defaultValue: null, length: 255, alias: What sex were you assigned at birth?, type: esriFieldTypeString
, Coded Values:
[female: Female]
, [male: Male]
, [prefer1: Prefer not to answer]
)
gender_identity
(
nullable: true, editable: true, defaultValue: null, length: 255, alias: How do you describe yourself?, type: esriFieldTypeString
, Coded Values:
[female_gi: Female]
, [male_gi: Male]
, [trans_female: Trans Female/Woman]
, ...6 more...
)
mh_consumer
(
nullable: true, editable: true, defaultValue: null, length: 255, alias: Are you a consumer of mental health services?, type: esriFieldTypeString
, Coded Values:
[yes_currently: Yes (Currently)]
, [yes_previously: Yes (Previously)]
, [no: No]
, ...1 more...
)
sud_consumer
(
nullable: true, editable: true, defaultValue: null, length: 255, alias: Are you a consumer of alcohol and/or drug services?, type: esriFieldTypeString
, Coded Values:
[yes_currently: Yes (Currently)]
, [yes_previously: Yes (Previously)]
, [no: No]
, ...1 more...
)
friend_family
(
nullable: true, editable: true, defaultValue: null, length: 255, alias: Are you a friend, family member, or loved one of a consumer of mental health services and/or alcohol and drug services?, type: esriFieldTypeString
, Coded Values:
[yes: Yes]
, [no: No]
, [prefer6: Prefer not to answer]
)
military
(
nullable: true, editable: true, defaultValue: null, length: 255, alias: Have you ever served in the military?, type: esriFieldTypeString
, Coded Values:
[yes_currently: Yes (Currently)]
, [yes_previously: Yes (Previously)]
, [no: No]
, ...1 more...
)
race
(
nullable: true, editable: true, defaultValue: null, length: 255, alias: Which category best describes your race (i.e. physical/ancestral characteristics)?, type: esriFieldTypeString
)
areas_fields
(
nullable: true, editable: true, defaultValue: null, length: 255, alias: Are you connected to any of the following stakeholder groups (Employed, Affiliated, Represent)?, type: esriFieldTypeString
)
disability
(
nullable: true, editable: true, defaultValue: null, length: 255, alias: Do you have a disability or other impairment that is expected to last longer than 6 months and substantially limits a major life activity, which is not the result of a severe mental illness?, type: esriFieldTypeString
, Coded Values:
[yes_dis: Yes]
, [no_dis: No]
, [prefer9: Prefer not to answer]
)
sb_living
(
nullable: true, editable: true, defaultValue: null, length: 255, alias: Do you live or work in San Bernardino County? If both, list the region you live in:, type: esriFieldTypeString
, Coded Values:
[sb_yes: Yes]
, [sb_no: No, I live and work in a neighboring California County]
, [prefer10: Prefer not to anwer]
)
sb_region
(
nullable: true, editable: true, defaultValue: null, length: 255, alias: If yes, which San Bernardino County Region do you live in?, type: esriFieldTypeString
, Coded Values:
[central_valley: Central Valley Region (e.g. Bloomington, Fontana, Grand Terrace, Rialto)]
, [deser_mountain: Desert/Mountain Region
(e.g. Adelanto, Amboy, Apple Valley, Baker, Barstow, Big Bear City, Clima, Earp, Fort Irwin, Hesperia, Hinkley, Joshua Tree, Landers, Ludlow, Morongo Valley, Mountain Pass, Needles, Nipton, Parker Dam, Phelan, Pioneertown, Sky Forest, Sugarloaf, 29 Palms, Wrightwood, Yermo, Yucca Valley)]
, [east_valley: East Valley
(e.g. Green Valley Lake, Highland, Lake Arrowhead, Loma Linda, Lytle Creek, Mentone, Patton, Redlands, Rimforest, Running Springs, San Bernardino, Yucapia)]
, ...1 more...
)
mhsa_updates
(
nullable: true, editable: true, defaultValue: null, length: 255, alias: In the future how would you like to receive MHSA updates? (Check all that apply), type: esriFieldTypeString
)
pivot_support
(
nullable: true, editable: true, defaultValue: null, length: 255, alias: Do you support the Program Improvements for Valued Outpatient Treatment (PIVOT) Innovation Project? Please answer yes or no, and please tell us why, type: esriFieldTypeString
, Coded Values:
[Yes: Yes]
, [No: No]
)
bhsa_challenges
(
nullable: true, editable: true, defaultValue: null, length: 9999, alias: What are your biggest concerns with transitioning from MHSA to BHSA?, type: esriFieldTypeString
)
medical_billable_services
(
nullable: true, editable: true, defaultValue: null, length: 255, alias: Does your organization currently provide Medi-Cal (Specialty Mental Health Services and Drug Medi-Cal Organized Delivery Services) billable services? If yes, provide examples of services, type: esriFieldTypeString
, Coded Values:
[Yes: Yes]
, [No: No]
)
services_examples
(
nullable: true, editable: true, defaultValue: null, length: 9999, alias: Please provide some examples., type: esriFieldTypeString
)
ehr_usage
(
nullable: true, editable: true, defaultValue: null, length: 255, alias: Does your organization currently have experience in accessing EHR/billing systems? If yes, which EHR/billing systems, type: esriFieldTypeString
, Coded Values:
[Yes: Yes]
, [No: No]
)
ehr_examples
(
nullable: true, editable: true, defaultValue: null, length: 9999, alias: Which EHR/billing systems does your organization use?, type: esriFieldTypeString
)
training_bill
(
nullable: true, editable: true, defaultValue: null, length: 9999, alias: What training or support does your organization need to adequately provide or strengthen knowledge about Medi-Cal billable services?, type: esriFieldTypeString
)
end_message
(
nullable: true, editable: true, defaultValue: null, length: 255, alias: Thank you for taking the time to complete this survey. Your feedback will help us improve the community planning process to better meet the needs of our community. All information provided will be kept confidential., type: esriFieldTypeString
)