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Organization Name*
First Name *
Last Name *
Email *
Mobile
Phone *
How do you want us to contact you? * -None-EmailPhoneEither
License Type*
Are you going to do a research study?* NoYes - Masters Thesis/DissertationYes - University Affiliated
How many unique clients do you treat annually?* —Please choose an option—Up to 100 patients/clients per year101-200 patients/clients per year201-300 patients/clients per year301-400 patients/clients per year401-500 patients/clients per year501-600 patients/clients per year601-700 patients/clients per year701-800 patients/clients per year801-900 patients/clients per year901 – 1000 Patients/clients per year1001-1100 patients/clients per year1101-1200 patients/clients per year1200+ patients/clients per year
If over 1200, please specify number of clients
How many providers will be utilizing the software? * (We don’t count Admin and Support users) Note: If your organization has part-time employees, please enter the number of FTE (Full Time Equivalent) providers.
Please select all that apply. Use CTRL+Left mouse button to select more than one option. Adventure TherapyAlcohol and Drug Rehabilitation FacilityBehavioral Health AgencyCommunity Health CenterCommunity Mental Health CenterCorrectionalCounseling CenterDay TreatmentEAGALAEAP ServicesEMR/ERH CompanyFFTGovernmentGovernment Mental/Behavioral Health (National, State, County, or City Level)Health Care CompanyHorse/Equine-Assisted TherapyHospitalInsurance/Managed Care ProviderInternationalIOP (Outpatient Program)IP (Inpatient)Juvenile JusticeMilitary (Active Duty)Military/GovernmentNon-ProfitNursing HomeOtherOutpatientPrivate or Solo PractitionerPrivate Practitioner ClinicPsychiatric HospitalResidential Treatment CenterSchoolState Health and Human ServicesStudentTelehealthTraining ClinicUniversityUniversity/College Counseling CenterUniversity/College Training ClinicUnknownVA Center/HospitalVeteransVendorWilderness Therapy
How did you hear about us? Use CTRL+Left mouse button to select more than one option. AGPAAPTCArticleAttended ConferenceColleagueCurrent userEAGALAEmail InquiryFFTGary BurlingameJoint CommissionMike LambertNATSAPOQ Measures WebsiteOtherPhone InquiryPrevious userResearch Project/ArticleSearch EngineOther Social MediaFacebookLinkedInX – TwitterInstagramYouTubeWord of MouthTraining ClinicUniversity/College Course
Who can we thank for the referral?
Other Social Media
Conference Attended
Adult Measures Use CTRL+Left mouse button to select more than one option. OQ®-45.2OQ®-30.2OQ®-ASCS-OQ® 2.0OQ®-10.2OQ® TA (Therapeutic Alliance)
Youth/Adolescent Measures Use CTRL+Left mouse button to select more than one option. Y-OQ® 2.01 CaregiverY-OQ® SR 2.0Y-OQ® 30.2 (CR) CaregiverY-OQ® 30.2 (SR) Self ReportY-OQ® TSM (CR) CaregiverY-OQ® TSM (SR) Self ReportY-OQ® TA (CR) Caregiver Therapeutic AllianceY-OQ® TA (SR) Self Report Therapeutic AllianceY-OQ® 2.01 TA CaregiverY-OQ® SR 2.0 TA
Group Measures Use CTRL+Left mouse button to select more than one option. OQ®-GRQOQ®-GQGCQ-S
Our instruments are translated into over 50 additional languages. Please let us know in the comments section if there are other languages needed
Other Measures Use CTRL+Left mouse button to select more than one option. ACE – Adverse Childhood ExperienceAUDIT – Alcohol Use Disorder Identification TestBAM – Brief Addiction MonitorBPRS – Brief Psychiatric Recovery ScaleCAGE – Substance Abuse Screening ToolCD-RISC Resilience ScaleCPSS-5 – Child PTSD Symptom ScaleClient Satisfaction Survey (free)CSSRS – Columbia Suicide Rating ScaleCSSRS – Columbia Suicide – Self ReportCSI-32 – Couples Satisfaction IndexDES-II – Dissociative Experience ScaleFIBSER Scale – Assesses Side Effects of Antidepressant treatmentGAD-7 – Generalized Anxiety Disorder ScreenHOPE-Scale – Resilience ScaleIIS-32 – Inventory of Interpersonal StrengthsMHC-SF – Mental Health ContinuumMDQ – Mood Disorder QuestionnaireMHSIP – Adult Satisfaction SurveyPCL-5 – PTSD Checklist for DSM 5PDI – Pain Disability IndexPHQ-9 – Patient Health QuestionnaireQIDS – Quick Inventory of Depressive SymptomatologyRAS-24 – Recovery Assessment ScaleWEQ = Workplace Experience QuestionnaireWSAS – Work and Social Adjustment ScalesYSS-Y - Youth Consumer Satisfaction SurveyYSS-F – Family Adult Consumer Satisfaction SurveyWHO-QOL – Quality of Life
Canadian French MeasuresUse CTRL+Left mouse button to select more than one option. OQ®-45.2OQ®-30.2OQ®-ASCOQ®-45.2 Substance UseY-OQ®2.01 CaregiverOQ®-45.2 TAOQ®-TAS-OQ® 2.0Y-OQ® 30.2 Caregiver/Self RptY-OQ®2.0 Self RptY-OQ® TSM Caregiver/YouthY-OQ® TA Caregiver/YouthAUDITCD-RISCColumbia SuicideColumbia Suicide – SRDES-IIFIBSER ScaleGAD-7Insomnia Severity IndexMARS - Med AdherenceMarital QuestionnaireMDQPain Disability IndexPCL-5PHQ-9QIDSWHO-QOLWSAS
Spanish MeasuresUse CTRL+Left mouse button to select more than one option. OQ®-45.2OQ®-30.2OQ®-ASCOQ®-45.2 Substance UseOQ®-45.2 TAOQ®-TAS-OQ® 2.0OQ®-30.2 TAY-OQ® 30.2 Caregiver/Self RptY-OQ®2.01 CaregiverY-OQ®2.0 Self RptY-OQ® TSM Caregiver/YouthY-OQ® TA Caregiver/YouthY-OQ®2.01 Caregiver TAY-OQ®2.01 Self Rpt TAY-OQ® 30.2 Caregiver/Self Rpt TAColumbia Suicide – SRGAD-7Marital QuestionnaireMDQMHSIPPHQ-9SUREYSS-YYSS-F
Brazilian Portuguese MeasuresUse CTRL+Left mouse button to select more than one option. OQ®-45.2OQ®-ASC
European Portuguese MeasuresUse CTRL+Left mouse button to select more than one option. OQ®-45.2OQ®-ASC
What is your current EMR/EHR system?
Any additional information we should know?
I'd like to receive relevant news from OQ Measures.
Please leave this field empty.
Are you going to do a research study? * -None-NoYes - Masters Thesis/DissertationYes - University Affiliated
Organization Size? -None-Individual (1 person in a solo practice)Small Group (2-5 people in a practice in one state/province)Intermediate Group (6-10) people in a practice in one state/province)Medium Group (11-15 people in a practice in one state/province)Large Group (16-50 people in a practice in one state/province)Facility (Over 50 people in one facility at one location)Single State (Over 50 people in a single state/province with more than one location)Multi-state (Any number of people within the confines of up to 10 states/provinces)International (Any number of people within a legal entity in multiple nations)
License Type *
Please select all that apply. Use CTRL+Left mouse button to select more than one option. Adventure TherapyBehavioral Health AgencyCommunity Mental Health CenterCorrectionalCounseling CenterDay TreatmentEAP ServicesEMR/EHR CompanyFFTGovernment Mental / Behavioral Health (national, state, county, or city level)Healthcare CompanyHorse/Equine TherapyHospitalInsurance/Managed Care ProviderInternationalIOP (Outpatient Program)IP (Inpatient)Juvenile JusticeMilitary (Active Duty)Nonprofit AgencyNursing HomeOtherOutpatientPrivate or Solo PractitionerPsychiatric HospitalRehabilitation Facility / Alcohol and DrugResidential Treatment CenterSchoolSmall Group PracticeStudentTelemental Health ServicesUniversityUniversity/College Counseling CenterUniversity/College Training ClinicVA CenterVendorVeteransWilderness
How did you hear about us? Use CTRL+Left mouse button to select more than one option. AGPAAPTCArticleAttended ConferenceCurrent userColleagueEAGALAEmail InquiryFFTGary BurlingameJoint CommissionMike LambertNATSAPOQ Measures WebsiteOtherPhone InquiryPrevious userResearch Project/ArticleSearch EngineOther Social MediaFacebookLinkedInX – TwitterInstagramYouTubeWord of MouthTraining ClinicUniversity/College Course
Adult Measures Use CTRL+Left mouse button to select more than one option. OQ®-45.2OQ®-30.2OQ®-ASCS-OQ® 2.0OQ®-10.2OQ® TA (Therapeutic Alliance)BPRSOQ®-WRAP (Military)
Youth/Adolescent Measures Use CTRL+Left mouse button to select more than one option. Y-OQ® 2.01 (CR) Caregiver ReportY-OQ® 2.0 (SR) Self ReportY-OQ® 30.2 (CR) CaregiverY-OQ® 30.2 (SR) Self ReportY-OQ® TSM (CR) CaregiverY-OQ® TSM (SR) Self ReportY-OQ® TA (CR) Caregiver Therapeutic AllianceY-OQ® TA (SR) Self Report Therapeutic AllianceY-OQ® 2.01 CR TA (Therapeutic Alliance)Y-OQ® 2.0 SR TA (Therapeutic Alliance)
Group Measures Use CTRL+Left mouse button to select more than one option. OQ®-GQOQ®-GRQGCQ-S
Our instruments are translated into over 50 languages. Please let us know in the comments section below if there are other languages needed.
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Contact Role —Please choose an option—3rd PartyAccounts ReceivableAuthorizerClinicalDecision MakerDirectorHelp DeskInfluencerInquirerOffice ManagerOffice StaffOtherPrimaryPrimary AccountingQualityReceptionistReferenceSalesTechnicalUserVendor
Other
How do you want us to contact you? * EmailTelephone
Are you going to do a research study? * YesNo
Are you a student? * YesNo
What is your annual census (the number of patients/clients per year that you serve)? * —Please choose an option—Up to 200 patients/clients per year201-400 patients/clients per year401-600 patients/clients per year601-800 patients/clients per year801-1000 patients/clients per year1001-1200 patients/clients per year1200+ patients/clients per year
If over 1200, how many patients/clients per year do you serve?
How many full-time equivalent (FTE) clinicians do you intend to license? * —Please choose an option—1 Clinician only2-5 Clinicians6-10 Clinicians11-15 Clinicians16-50 Clinicians51+ Clinicians at 1 facility51+ Clinicians at multiple facilities in 1 state or province51+ Clinicians in multiple states or provinces51+ Clinicians in multiple countries
Are you/your organization utilizing an EHR/EMR system? If, yes, please include EHR/EMR system/company that you are utilizing?
Please select all the settings of care that apply to your organization * Alcohol and Drug Rehabilitation FacilityBehavioral Health AgencyCommunity Mental Health CenterCorrectionalCounseling CenterDay TreatmentEAP ServicesEMR/EHR CompanyFFTGovernment Mental / Behavioral Health (national, state, county or city level)Healthcare CompanyHorse/Equine TherapyHospitalInsurance/Managed Care ProviderInternationalIOP (Outpatient Program)IP (Inpatient)Juvenile JusticeMilitary (Active Duty)Nonprofit AgencyNursing HomeOtherOutpatientPrivate or Solo PractitionerPsychiatric HospitalResidential Treatment CenterSchoolSmall Group PracticeStudentTelemental Health ServicesUniversityUniversity/College Counseling CenterUniversity/College Training ClinicVA CenterVendorVeteransWilderness or Adventure TherapyNon-profit Agency
How did you hear about us? (Check all that apply.) * AGPAAPTCArticleColleagueConferenceCurrently useEAGALAEmail InquiryFacebookFFTGary BurlingameJoint CommissionLinkedinMike LambertNATSAPOtherPhone InquiryPreviously usedReferralResearch Project/ArticleSearch EngineTraining ClinicTwitterYouTubeWord Of Mouth
Name of Colleague
Name of Conference
Specify Company or University
Name of Facebook Group
Referral
Word of Mouth
Select the samples you would like to download.
Adult Measures: OQ®-45.2OQ® TA (Therapeutic Alliance)OQ®-30.2OQ®-ASCS-OQ® 2.0OQ®-10.2BPRS
Youth/Adolescent Measures: Y-OQ® 2.01Y-OQ® SR 2.0Y-OQ® 30.2 SRY-OQ® TSM ParentY-OQ® TSM YouthY-OQ® PR TA (Therapeutic Alliance)Y-OQ® SR TA (Therapeutic Alliance)
Group Measures: OQ®-GRQOQ®-GQGCQ-S
Military Measures: OQ®-WRAP
Which format are you interested in? * OQ®-Analyst SoftwareOQ®-PaperOQ®-Access
Yes, I'd like to receive relevant news from OQ Measures. I can sign off easily at any given time.
Your Comments/Questions
How do you want us to contact you? * EmailPhoneEither
What is your annual census (the number of patients/clients per year that you serve)? * —Please choose an option—Up to 100 patients/clients per year101-200 patients/clients per year201-300 patients/clients per year301-400 patients/clients per year401-500 patients/clients per year501-600 patients/clients per year601-800 patients/clients per year801-1000 patients/clients per year1001-1200 patients/clients per year1200+ patients/clients per year
Please Specify your census, if over 1200
Please tell us who referred you
Referring Clinic
Other Measures: Y-OQ® 2.01Y-OQ® SR 2.0Y-OQ® 30.2 SRY-OQ® TSM ParentY-OQ® TSM YouthY-OQ® PR TA (Therapeutic Alliance)Y-OQ® SR TA (Therapeutic Alliance)
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