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  5. Demographic Questionaire
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Questions marked with an * are required Exit Survey
 
 
* What is your age?
 
18 to 24
 
25 to 34
 
35 to 44
 
45 to 54
 
55 to 64
 
65 to 74
 
75 or older
 
 
 
What is your gender?
 
Male
 
Female
 
 
 
What is your professional degree?
 
PhD Psychology
 
PsyD Psychology
 
Masters in Social Work
 
Marriage and Family Therapist
 
Educational Psychologist
 
 
 
How many years have you been licensed?
 
3 to 7 years
 
8 to 12 years
 
13 to 17 years
 
18 years above
 
 
 
What type of agency are you employed by? (Check all that apply)
 
Community mental health
 
Private practice
 
Substance abuse treatment facility
 
Government agency
 
Outpatient clinic
 
Residential mental health setting
 
Runaway crisis resolution center

 
 
 
What is your position within the agency you are employed?
   
 
 
 
What is the primary population served within the agency which you are employed? (Check all that apply)
 
Children
 
Adolescents
 
Adults
 
Geriatrics
 
Couples
 
Families

 
 
 
What are the ages of children and adolescents treated at the agency which you are employed?
 
0 to 3 years
 
4 to 8 years
 
9 to 12 years
 
3 to 16 years
 
17 and above
 
 
 
What is the ethnic composition of clients treated at your agency? (Check all that apply)
 
White
 
Hispanic or Latino
 
Black or African American
 
Native American or American Indian
 
Asian/Pacific Islander
 
Other
 
 
 
What mental health services are provided at the agency which you are employed? (Check all that apply)
 
Individual therapy
 
Group therapy
 
Psychological assessment
 
Medication distribution
 
Medication management