Behavioral Health Mapping Survey Name of Organization or Business* Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneFaxWebsite Email Brief description of the services your organization or business providesCounties ServedCheck all that apply Adair Adams Allamakee Appanoose Audubon Benton Black Hawk Boone Bremer Buchanan Buena Vista Butler Calhoun Carroll Cass Cedar Cerro Gordo Cherokee Chickasaw Clarke Clay Clayton Clinton Crawford Dallas Davis Decatur Delaware Des Moines Dickinson Dubuque Emmet Fayette Floyd Franklin Fremont Greene Grundy Guthrie Hamilton Hancock Hardin Harrison Henry Howard Humboldt Ida Iowa Jackson Jasper Jefferson Johnson Jones Keokuk Kossuth Lee Linn Louisa Lucas Lyon Madison Mahaska Marion Marshall Mills Mitchell Monona Monroe Montgomery Muscatine O’Brien Osceola Page Palo Alto Plymouth Pocahontas Polk Pottawattamie Poweshiek Ringgold Sac Scott Shelby Sioux Story Tama Taylor Union Van Buren Wapello Warren Washington Wayne Webster Winnebago Winneshiek Woodbury Worth Wright Population ServedCheck all that apply Children ages 0 through 5 years of age Children ages 6 through 12 years of age Adolescents age 13 through 18 years of age Adults Seniors (65 and older) What type of providers does your organization have available?Check all the apply Licensed Psychologist LMCJ LMSW LMHP LISW ARNP Physician Assistant Psychiatrist Certified Prevention and/or Treatment Professional in the state of Iowa Payment Methods AcceptedCheck all that apply Medicaid – Iowa Total Care Blue Cross Blue Shield County Funding Medicaid – Amerigroup Iowa Medicaid – AmeriHealth Caritas Medicaid – Fee for Service Medicaid – United Health Care Most Insurances No Cost Private Pay Sliding Fee Scale What type of children services does your organization provide?Check all that apply Child therapy for children ages 0-12 Adolescent therapy for children ages 13-18 Assessments Specialized therapy (i.e. play art, autism, pediatrics integrated home health, etc.) EMDR – Child What type of adult services does your organization provide?Check all that apply Individual and/or adult therapy (i.e. dialectical behavioral therapy, EMDR- Adult, etc.) Jail services Gambling addition Adult integrated home health services Geriatric special services What type of assessments does your organization provide?Check all that apply. Screenings (substance abuse evaluation, ADHD, mental health, etc.) Medication management/psychiatric services Mobile crisis and/or crisis stabilization services Community based services Behavioral health intervention services (BHIS) NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.