Do you live in New Jersey? If no, click other and specify what state.
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?
What is your child’s gender?
What is your child's race/ethnicity?
What is your child's age?
What is your child’s date of birth?
What is your child’s living arrangement?
Please indicate your child's mental health diagnosis (you may indicate more than one):
Does your child attend school?
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?
My child currently is involved in and/or receives services from the following systems?
(please indicate one or more):
My child has received services for the following number of years:
My child is currently taking medication for their mental health disorders.
If yes, list medications. If no write not applicable.
Has your child EVER received treatment on a psychiatric inpatient unit of a hospital? (CCIS)
Has your child EVER been in a residential treatment facility?
Has your child EVER been arrested?
Has your child EVER been incarcerated?
Has your child EVER been on probation?
Is your child CURRENTLY in a hospital?
Is your child CURRENTLY in a residential treatment center?
Is your child CURRENTLY incarcerated?
If yes where? If no write not applicable.
Is your child CURRENTLY on probation?
How often does your child attend school?
How well is your child doing in school, in generally?
How satisfied are you with your child’s academic progress?
Are you satisfied with how schools and other educational programs are handling your child’s mental health diagnosis?
Is your child satisfied with how schools and other educational programs are handling their child’s mental health diagnosis?
How many friends does your child have?
How satisfied are you with your child’s friendships?
Describe your child’s attitude, in general
How hopeful is your child about their future?
How does your child feel about themselves?
I feel that I have the right to approve all services my child receives.
I feel confident about participating in treatment planning or IEP meetings for my child.
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.
I make sure that professionals understand my opinions about the services my child needs.
I am actively involved in making decisions about what services my child needs.
I stay in regular contact with those who are providing services for my child.
Professionals treat me as an equal partner when deciding services for my child
Do you feel that all of your child’s mental health, school and personal needs are being met?
Do you feel that the services being offered to your child are tailored to his/her needs?
Do you feel that the services being offered to your child are tailored to his/her strengths?
Are you satisfied with the level of care your child is receiving in reference to their mental health diagnosis?
Is your child satisfied with the level of care they are receiving with their mental heath diagnosis?
Do you agree with your child’s current treatment plan?
Does your child CURRENTLY have a case manager?
If yes, from which agency/agencies? If no, write not applicable.
Has your child been exposed to any traumatic events?
If yes please explain. If no, write not applicable.
What is your race/ethnicity?
What is your current parenting status?
What is your marital status?
What is your employment status?
What type of health insurance do you have?
What is your educational status/highest grade completed:
What is the language you use most often at home?
Have you or the child’s parent or caregiver ever been incarcerated?
If applicable, please indicate your mental health diagnosis. If no, write not applicable.
I receive services from the following organizations:
What is your family’s Total Yearly Income: