California Fire Service Behavioral Health Program Survey

California Fire Service Behavioral Health Program Survey
The purpose of this survey is to identify behavioral health and peer support resources. Information collected will help develop a statewide resource directory and improve access to behavioral health support for fire service personnel and their families.
Department Name (as it will appear on the Healing Our Own website):
Department County:
Approximate Department Size:
Behavioral Health Program Resources

Please identify the behavioral health resources currently available through your department.
Does your department have a designated Behavioral Health Program Coordinator/Lead (not just Peer Support Lead)?
Name:

First NameLast Name
Email:
example@example.com
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Does your department have a designated Peer Support Team Lead?
Name:

First NameLast Name
Email:
example@example.com
Does your department have a formal Peer Support Team?
Number of active peer supporters:
Have your peer support team members completed formal peer support training?
Training Provider:
Training Provider Contact:
Name:

First NameLast Name
Email:
example@example.com
Does your Peer Support Team include non-fire suppression personnel?
Select all that apply

Other
Does your department have a Fire Service Chaplain Program?
Select all that apply

Other
Does your department provide access to culturally competent clinicians?
How are clinicians provided?

Other
Does your department have access to any specialized peer support resources?
How are clinicians provided?

Other
Does your department have a preferred wellness treatment facility for referrals related to PTSD, substance use, or other behavioral health concerns?
Preferred Wellness Treatment Facility :
Personnel Eligible to Access Behavioral Health Resources

Please identify which groups have access to your department's behavioral health resources.
Firefighters/Engineers:
Fire Officers:
Chief Officers:
Fire Prevention:
EMS Personnel:
Dispatch/Communications:
Lifeguards:
Administrative/Support Staff:
Retirees:
Family Members:
Not listed:
Should be Empty:

California Fire Service Behavioral Health Program Survey

Behavioral Health Program Resources

Personnel Eligible to Access Behavioral Health Resources