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Medication Survey
In what NJ county do you currently reside?
What is the child’s sex?
What is your relationship to your child?
What is your child's age?
What is your child's race/ethnicity?
Please indicate which type of medical insurance your child has?
Please indicate your child's mental health diagnosis (you may indicate more than one):
Please indicate which medication(s) your child is currently taking (you may select more
than one):
Who initially prescribed your child's medication?
Who currently provides refill prescriptions for your child’s medication?
My child currently is involved in and/or receives services from the following systems
(please indicate one or more):
Do you feel that mental health resources (private and/or public) have been easily accessible for
your child? If not, what are some barriers to their care? Please describe in the space below.
What is your email? 
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