No ⓪ If yes, the reports are also separated by gender and age for analysis Yes ② None ⓪ 1 category (e.g.MNS) ① Reporting categories used for mental, neurological and substance use disorders Several categories ② (e.g. UNHCR HIS) To Interviewer: If report is available please attach to the checklist 9. Average Score ( ) (= sum of all scored items divided by total # of items scored) Notes and Recommendations: 10. Social Indicators The Health Facility has the following characteristics: No The health care facilities is in safe walking distance of ⓪ affected/target communities Yes ② Health care provision is organized in a way that respects No ⓪ privacy (e.g. curtain around consultancy area, private room) Yes ② Services are provided: free of charge $ per consultation: _____ At least 1 staff member per clinic speaks the local language No ⓪ or dialect(s) Yes N/A ② 10. Average Score ( ) (= sum of all scored items divided by total # of items scored) Notes and Recommendations: 11. Referral indicators 11a. Health know: Referral options to the specialized mental health No ⓪ services (e.g. staff know the location, contact, costs Yes ② and referral procedures for closest specialized Contacts: services) Referral options to the protection agencies/social No ⓪ services (e.g.concerns regarding physical and sexual Yes ② abuse of children and adults) Contacts: Referral & follow up protocol for emergency No ⓪ including at-risk patients (e.g. cases of Yes ② Details: 11. Average 11a ( ) (= sum of all scored items divided by total # of items scored) 11b. In the last 2 weeks mental health-related referrals occurred to PHC from:
If yes, the reports are also separated by gender and age for analysis ⓪ No ② Yes Reporting categories used for mental, neurological and substance use disorders ⓪ None ① 1 category (e.g.MNS) ② Several categories (e.g. UNHCR HIS) To Interviewer: If report is available please attach to the checklist 9. Average Score (= sum of all scored items divided by total # of items scored) ( ) Notes and Recommendations: 10. Social Indicators The Health Facility has the following characteristics: The health care facilities is in safe walking distance of affected/target communities ⓪ No ② Yes Health care provision is organized in a way that respects privacy (e.g. curtain around consultancy area, private room) ⓪ No ② Yes Services are provided: free of charge $ per consultation: _____ At least 1 staff member per clinic speaks the local language or dialect(s) ⓪ No ② Yes N/A 10. Average Score (= sum of all scored items divided by total # of items scored) ( ) Notes and Recommendations: 11. Referral indicators 11a. Health know: Referral options to the specialized mental health services (e.g. staff know the location, contact, costs and referral procedures for closest specialized services) ⓪ No ② Yes Contacts: Referral options to the protection agencies/social services (e.g.concerns regarding physical and sexual abuse of children and adults) ⓪ No ② Yes Contacts: Referral & follow up protocol for emergency including at-risk patients (e.g. cases of ⓪ No ② Yes Details: 11. Average (= sum of all scored items divided by total # of items scored) 11a ( ) 11b. In the last 2 weeks mental health-related referrals occurred to PHC from:
IMC%202017%20PHC%20MH%20Integration%20Checklist%20Sample_designed.docx