CPSP Perinatal Depression Survey

Please fill out all of the following information:

  1. Provider Name:

Address:______

City:______Zip:______

Provider email:______

Phone number:______Fax:______

Name and title of person completing the survey:

______

How many years of CPSP experience do you have?

 Less than 6mo  6months – 1 year  1- 5 years  Over 5 years

  1. Do you use a depression-screening tool? If so which one do you use?

 We do not screen for depression (skip to question 4)

 Edinburgh  PHQ-9  CED-D  PDSS  Other (please specify)______

  1. How often do you administer the depression-screening tool?

 Initial visit only  Once each trimester  Postpartum only  All prenatal visits

(Skip to question 5)

  1. What are the reasons you do not use a depression screening tool? Check all that apply.

 No Time

 No Reimbursement

 We don’t have patients that are depressed

 No resources to refer patients that are depressed

 Do not feel comfortable asking questions about depression

 Patients do not like us to ask personal questions

 Other (please specify)______

  1. Where do you refer patients that need further evaluation and treatment? Check all that apply.

 Refer to my own services (please specify)______

 Refer to mental health clinic/agency (please specify)______

 Refer to individual mental health provider (please specify)______

 Refer to hospital social worker (please specify)______

 Refer to other type of provider (please specify)______

 I don’t know where to refer

GO TO NEXT PAGE

  1. Estimate the percentage of patients that follow up with a referral.

 0-25%  26-50%  51-75%  76-100%  Don’t Know

 We do not follow up with patients to see if they kept their referral(s)

  1. If you are interested in receiving free training about perinatal depression, what topics would you like to learn more about? Check all that apply.

 Screening for perinatal depression

 Treatment

 Resources/Referrals

 I am not interested in perinatal depression training

  1. Research shows there may be a relationship between a patient’s Body Mass Index (BMI) and depression.

Do you document pre-pregnancy BMI for all patients?  Yes  No

If yes, where in the chart?______

If yes, who is responsible for documenting the BMI?______

  1. Approximately how many new prenatal clients does your office sees each year? ______

What is the approximate racial/ethnic makeup of your clients (in percentage out of 100%)? Enter a number from 0 to 100 for each ethnicity. The total must add up to 100.

% African American______

% Asian/Pacific Islander______

% Caucasian______

% Latina______

% Multiracial______

% Other______

Please fax completed survey – no cover page needed - to: CPSP at 213.639.1034 or mail to:

CPSP, 600 S. Commonwealth Ave., Rm. 800, Los Angeles, CA 90005

THANK YOU!

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