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Parent/Caregiver and Child Questionnaire
Do you live in New Jersey? If no, click other and specify what state.
Yes
Other
If yes to the previous question, in what county do you currently reside? If no, write not applicable.
What is your relationship to your child?
Biological Parent
Resource Parent
Adoptive Parent
Kinship Provider
Family Member
Other
What is your child’s gender?
Female
Male
What is your child's race/ethnicity?
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other
What is your child's age?
What is your child’s date of birth?
What is your child’s living arrangement?
Home
Resource Home (Foster)
Kinship
Other Relative
Hospital (CCIS)
Residential
Incarcerated
Other
Please indicate your child's mental health diagnosis (you may indicate more than one):
Autism Spectrum Disorders
ADD
ADHD
Learning Disorder
Dyslexia
Specific Learning Disorder
Social Communication Disorder
Schizoaffective Disorder
Schizoaffective Bipolar Type
Schizoaffective disorder Depressive Type
Schizophrenia
Bipolar 1
Bipolar 2
Cyclothymic Disorder
Disruptive Mood Dysregulation Disorder
Major Depressive Disorder
Persistent Depressive Disorder (Dysthymia)
Separation Anxiety Disorder
Social Anxiety Disorder
Generalized Anxiety Disorder
Obsessive Compulsive Disorder
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
Posttraumatic Stress Disorder
Adjustment Disorder
Oppositional Defiant Disorder
Intermittent Explosive Disorder
Conduct disorder
Substance use disorder
Unknown
Other (Please specify all)
Does your child attend school?
Yes
No
If yes to the previous question, what grade? If no write not applicable.
If your child does not attend school, please explain. If they do attend school write not applicable.
My child has the following health insurance?
Private
Medicaid
New Jersey Family care
None
My child currently is involved in and/or receives services from the following systems?
(please indicate one or more):
Children’s Mental Health
Perform Care
Unified Care Management Organization (UCM)
Care Management Organization (CMO)
Youth Case Management (YCM)
Mobile Response & Stabilization Services (MRSS)
Child Welfare DCP&P
Juvenile Justice
Special Education
TANF
Not Applicable
Other
My child has received services for the following number of years:
My child is currently taking medication for their mental health disorders.
Yes
No
If yes, list medications. If no write not applicable.
Has your child EVER received treatment on a psychiatric inpatient unit of a hospital? (CCIS)
Yes
No
Has your child EVER been in a residential treatment facility?
Yes
No
Has your child EVER been arrested?
Yes
No
Has your child EVER been incarcerated?
Yes
No
Has your child EVER been on probation?
Yes
No
Is your child CURRENTLY in a hospital?
Yes
No
Is your child CURRENTLY in a residential treatment center?
Yes
No
Is your child CURRENTLY incarcerated?
Yes
No
If yes where? If no write not applicable.
Is your child CURRENTLY on probation?
Yes
No
How often does your child attend school?
Less than weekly
Attend school sometimes
Always attends
How well is your child doing in school, in generally?
Performs poorly
Performs adequately
Performs well
How satisfied are you with your child’s academic progress?
Extremely dissatisfied
Dissatisfied
Satisfied
Extremely satisfied
Are you satisfied with how schools and other educational programs are handling your child’s mental health diagnosis?
Extremely dissatisfied
Dissatisfied
Satisfied
Extremely satisfied
Not Applicable
Is your child satisfied with how schools and other educational programs are handling their child’s mental health diagnosis?
Extremely dissatisfied
Dissatisfied
Satisfied
Extremely satisfied
Not Applicable
How many friends does your child have?
No friends
Some friends
Many close friends
How satisfied are you with your child’s friendships?
Extremely dissatisfied
Dissatisfied
Satisfied
Extremely satisfied
Describe your child’s attitude, in general
Negative
Average for age/gender
Positive
How hopeful is your child about their future?
Hopeless
Average for age/gender
Hopeful
How does your child feel about themselves?
Self-hating
Average for age/gender
Self-loving
I feel that I have the right to approve all services my child receives.
Rarely
Sometimes
Usually
I feel confident about participating in treatment planning or IEP meetings for my child.
Rarely
Sometimes
Usually
I know how to get services for my child, and I know the steps to take when I am concerned about the services my child is or is not receiving.
Rarely
Sometimes
Usually
I make sure that professionals understand my opinions about the services my child needs.
Rarely
Sometimes
Usually
I am actively involved in making decisions about what services my child needs.
Rarely
Sometimes
Usually
I stay in regular contact with those who are providing services for my child.
Rarely
Sometimes
Usually
Professionals treat me as an equal partner when deciding services for my child
Rarely
Sometimes
Usually
Do you feel that all of your child’s mental health, school and personal needs are being met?
Rarely
Sometimes
Usually
Do you feel that the services being offered to your child are tailored to his/her needs?
Rarely
Sometimes
Usually
Do you feel that the services being offered to your child are tailored to his/her strengths?
Rarely
Sometimes
Usually
Are you satisfied with the level of care your child is receiving in reference to their mental health diagnosis?
Extremely dissatisfied
Dissatisfied
Satisfied
Extremely satisfied
Is your child satisfied with the level of care they are receiving with their mental heath diagnosis?
Extremely dissatisfied
Dissatisfied
Satisfied
Extremely satisfied
Not Applicable
Do you agree with your child’s current treatment plan?
-- Select --
No
Somewhat
Yes
Did you sign the plan?
Yes
No
Does your child CURRENTLY have a case manager?
Yes
No
If yes, from which agency/agencies? If no, write not applicable.
Has your child been exposed to any traumatic events?
Yes
No
If yes please explain. If no, write not applicable.
What is your gender?
Female
Male
What is your age range?
-- Select --
22 years or younger
23-29 years
30-45 years
46-60 years
60 plus years
What is your race/ethnicity?
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other
What is your current parenting status?
-- Select --
Single Parent
Two parents at home
Joint or shared custody
Resource Parents (foster)
Children with relatives
Other
What is your marital status?
-- Select --
Married
Single
Divorced
Separated
Widowed
What is your employment status?
-- Select --
Employed
Unemployed
FT Student
Self Employed
Other
What type of health insurance do you have?
-- Select --
Private
Medicaid
None
What is your educational status/highest grade completed:
What is the language you use most often at home?
-- Select --
English
Spanish
Other
Have you or the child’s parent or caregiver ever been incarcerated?
Yes
No
If applicable, please indicate your mental health diagnosis. If no, write not applicable.
I receive services from the following organizations:
Family Support Organization (FSO)
Family Success Center
Social Services / Welfare / TANF
Mental Health
Not Applicable
Other
What is your family’s Total Yearly Income:
-- Select --
0 – $15,000
$15,001 - $20,000
$20,001 - $30,000
$30,001 - $40,000
$40,001 - $50,000
$50,001 - $60,000
$60,001 and above
What is your email?
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