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Required format:

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2024 Map Questionnaire for EBP Providers

This survey is from the Louisiana Center for Evidence to Practice, in partnership with the Louisiana Office of Behavioral Health. We are in the process of updating our map of organizations providing evidence-based behavioral health practices for children, youth, and their parents using Medicaid. This map is hosted online at our website laevidencetopractice.com. It is interactive and it allows the community to identify providers to make appropriate referrals.

This survey should take 10 - 15 minutes to complete. We will follow up with you via telephone or email if there are any questions. Thank you for your participation. Don't hesitate to contact the Center at EvidenceToPractice@lsuhsc.edu with any questions.

Agency Name:

* must provide value

At how many locations do you offer EBP services?

* must provide value

First and Last Name of Primary Contact at Agency Location:

* must provide value

Email for Agency Location:

* must provide value

Phone Number for Agency Location:

* must provide value

Street Address for Agency Location:

* must provide value

City for Agency Location:

* must provide value

State for Agency Location:

* must provide value

Zip Code for Agency Location:

* must provide value

Which Parish is this Agency Location part of?

What is the billing NPI for this agency location (not practitioner-specific)?

* must provide value

Is this Agency Location part of a Human Services District/Authority?

Yes

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Which Human Services District/Authority is this Agency Location part of?

First and Last Name of Primary Contact at 2nd Agency Location:

* must provide value

Email for 2nd Agency Location:

* must provide value

Phone Number for 2nd Agency Location:

* must provide value

Street Address for 2nd Agency Location:

* must provide value

City for 2nd Agency Location:

* must provide value

State for 2nd Agency Location:

* must provide value

Zip Code for 2nd Agency Location;

* must provide value

Which Parish is this 2nd Agency Location part of?

What is the billing NPI for 2nd Agency Location (not practitioner-specific)?

* must provide value

Is this 2nd Agency Location part of a Human Services District/Authority?

Yes

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Which Human Services District/Authority is this 2nd Agency Location part of?

First and Last Name of Primary Contact at 3rd Agency Location:

* must provide value

Email for 3rd Agency Location:

* must provide value

Phone Number for 3rd Agency Location:

* must provide value

Street Address for 3rd Agency Location:

* must provide value

City for 3rd Agency Location:

* must provide value

State for 3rd Agency Location:

* must provide value

Zip Code for 3rd Agency Location;

* must provide value

Which Parish is this 3rd Agency Location part of?

What is the billing NPI for 3rd Agency Location (not practitioner-specific)?

* must provide value

Is this 3rd Agency Location part of a Human Services District/Authority?

Yes

reset

Which Human Services District/Authority is this 3rd Agency Location part of?

First and Last Name of Primary Contact at 4th Agency Location:

* must provide value

Email for 4th Agency Location:

* must provide value

Phone Number for 4th Agency Location:

* must provide value

Street Address for 4th Agency Location:

* must provide value

City for 4th Agency Location:

* must provide value

State for 4th Agency Location:

* must provide value

Zip Code for 4th Agency Location;

* must provide value

Which Parish is this 4th Agency Location part of?

What is the billing NPI for 4th Agency Location (not practitioner-specific)?

* must provide value

Is this 4th Agency Location part of a Human Services District/Authority?

Yes

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Which Human Services District/Authority is this 4th Agency Location part of?

First and Last Name of Primary Contact at 5th Agency Location:

* must provide value

Email for 5th Agency Location:

* must provide value

Phone Number for 5th Agency Location:

* must provide value

Street Address for 5th Agency Location:

* must provide value

City for 5th Agency Location:

* must provide value

State for 5th Agency Location:

* must provide value

Zip Code for 5th Agency Location;

* must provide value

Which Parish is this 5th Agency Location part of?

What is the billing NPI for 5th Agency Location (not practitioner-specific)?

* must provide value

Is this 5th Agency Location part of a Human Services District/Authority?

Yes

reset

Which Human Services District/Authority is this 5th Agency Location part of?

First and Last Name of Primary Contact at 6th Agency Location:

* must provide value

Email for 6th Agency Location:

* must provide value

Phone Number for 6th Agency Location:

* must provide value

Street Address for 6th Agency Location:

* must provide value

City for 6th Agency Location:

* must provide value

State for 6th Agency Location:

* must provide value

Zip Code for 6th Agency Location;

* must provide value

Which Parish is this 6th Agency Location part of?

What is the billing NPI for 6th Agency Location (not practitioner-specific)?

* must provide value

Is this 6th Agency Location part of a Human Services District/Authority?

Yes

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Which Human Services District/Authority is this 6th Agency Location part of?

Which Medicaid Managed Care Organization (MCO) payment plans are accepted by your agency?
Please select all that apply.

* must provide value

Aetna

AmeriHealth Caritas

Healthy Blue

Humana

Louisiana Healthcare Connections

Magellan

United Healthcare

I do not accept Medicaid

Which of the following EBPs are offered at your agency?
Please select all that apply

* must provide value

EB02: Child-Parent Psychotherapy (CPP)

EB03: Parent-Child Interaction Therapy (PCIT)

EB04: Youth PTSD Treatment (YPT)

EB05: Preschool PSTD Treatment (PPT)

EB06: Positive Parenting Practices, Level 4 (Triple P)

EB07: Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

EB08: Eye Movement Desensitization and Reprocessing (EMDR)

Currently in EBP training

Completed training, currently in consultation

Completed consultation, working towards certification

Applied for certification

Certified in this EBP

CPP

PCIT

YPT

PPT

Triple P

TF-CBT

EMDR

Approximately HOW MANY CLIENTS did your agency see with CPP in 2022?
Please count each family as one client/case.

Approximately HOW MANY CLIENTS did your agency see with PCIT in 2022?
Please count each family as one client/case.

Approximately HOW MANY CLIENTS did your agency see with YPT in 2022?
Please count each family as one client/case.

Approximately HOW MANY CLIENTS did your agency see with PPT in 2022?
Please count each family as one client/case.

Approximately HOW MANY CLIENTS did your agency see with Triple P in 2022?
Please count each family as one client/case.

Approximately HOW MANY CLIENTS did your agency see with TF-CBT in 2022?
Please count each family as one client/case.

Approximately HOW MANY CLIENTS did your agency see with EMDR in 2022?
Please count each family as one client/case.

Did you know about the EBP Tracking Code for the following EBPs: CPP, PCIT, YPT, PPT, Triple P, TF-CBT, and/or EMDR?

* must provide value

Yes

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Have you used the EBP Tracking Codes when billing?

* must provide value

Yes

Not Sure

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Did you know you can view the EBP Qualifications & Billing Guide as a resource available on our website:
https://laevidencetopractice.com/wp-content/uploads/2023/11/EBP-Qualification-and-Billing-Guide_Updated_11.9.23_FINAL.pdf

* must provide value

Yes

reset

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