Experiencing Access Barriers?

We want to know about it so we can help!

This form is designed for care coordinators & resource navigators to report instances of service gaps and/or barriers. The results of this survey will be anonymously submitted to the Enhance the Coordination of Care Action Team with the Behavioral Health Initiative and to MITHRIVE, both of which are projects of the Northwest CHIR. Both of these projects will use the resulting data to address the systemic issues contributing to these access barriers. You will not receive any follow-up communications based on your responses to this form.

Please help us identify and keep track of the service gaps and access barriers in our region by submitting your and your clients’ personal experiences.

Access Barrier Reporting Form

"*" indicates required fields

Name
What agency are you affiliated with?
Client Age*
How old is the client you were attempting to locate services for? (check more than one for each family member)
Client Location*
What county does your client reside in?

Client Family*
How many people are in your client’s family?
Client Income*
What is the approximate average household income of your client?
Client Insurance*
What type of insurance does your client have?

Type of Service Needed for Client

In the section below, choose the category for the type of service you were attempting to access on behalf of your client and then select the service from the drop down list.
Please describe a service not listed in the options above that your client is in need of.
Reason for Access Barrier*
What is the main reason you were unable to access that service? (Please select one only)

Provide more details for the reason you were unable to access a service.
Service Coordination Challenges*
Did you experience any service coordination challenges? If so, what were they?
Please provide any other relevant details about the specific program / service you were attempting to access and the barriers you encountered. Is there anything else we should know to help us understand the challenges you faced in coordinating access to care for this client?