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Medication Survey

In what NJ county do you currently reside?

What is the child’s sex?

Female

Male

What is your relationship to your child?

Biological Parent

Foster/Resource Parent

Adoptive Parent

Kinship Provider

Family Member

Other

What is your child's age?

0-4 years

5-10 years

11-14 years

15-17 years

18 years or older

What is your child's race/ethnicity?

African-American

Asian

Caucasian

Hispanic, Latino, or Spanish Origin

Native American

Native Hawaiian or Other Pacific Islander

Other

Please indicate which type of medical insurance your child has?

Private Insurance

Medicaid

None

Other

Please indicate your child's mental health diagnosis (you may indicate more than one):

Intellectual Disabilities

Communication Disorder

Autism Spectrum Disorder

Schizophrenia

Schizoaffective Disorder

Bipolar I Disorder

Bipolar II Disorder

Cyclothymic Disorder

Disruptive Mood Dysregulation Disorder

Major Depressive Disorder/Other Depressions

Dysthymia/ Persistent Depressive Disorder

Separation Anxiety Disorder

Generalized Anxiety Disorder

Social Anxiety Disorder

Obssessive Compulsive Disorder

Reactive Attachment Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder (PTSD)

Acute Stress Disorder

Adjustment Disorder

Oppositional Defiant Disorder (ODD)

Intermittent Explosive Disorder

Conduct Disorder

Attention-deficit/Hyperactivity Disorder (ADD/ADHD)

Substance Use Disorder

Unknown Diagnosis

Undiagnosed

No disability

Other

Please indicate which medication(s) your child is currently taking (you may select more

than one):

Alprazolam (Xanax)

Amitriptyline (Elavil)

Aripiprazole (Abilify)

Asenapine (Saphris)

Atomoxetine (Strattera)

Bupropion (Wellbutrin)

Buspirone (BuSpar)

Carbamazepine (Tegretol)

Chlorpromazine (Thorazine)

Clomipramine (Anafranil)

Clonazepam (Klonopin)

Eszopiclone (Lunesta)

Fluoxetine (Prozac)

Fluphenazine (Prolixin)

Fluvoxamine (Luvox)

Guanfacine (Tenex, Intuniv)

Haloperidol (Haldol)

Iloperidone (Fanapt)

Imipramine (Tofranil)

Lamotrigine (Lamictil)

Lithium (Lithium carbonate, Eskalith)

Lorazepam (Ativan)

Paroxetine (Paxil)

Phenelzine (Nardil)

Quetiapine (Seroquel)

Risperidone (Risperdal)

Sertraline (Zoloft)

Thioridazine (Mellaril)

Thiothixene (Navane)

Tranylcypromine (Parnate)

Trazodone (Desyrel)

Trifluoperazine (Stelazine)

Clonidine (Kapvay, Catapres)

Clozapine (Clozaril)

Desvenlafaxine (Pristiq)

Dextroamphetamine (Dexedrine, Adderal, Vyanse, Procentra)

Diazepam (Valium)

Diphenhydramine (Benadryl)

Duloxetine (Cymbalta)

Escitalopram (Lexapro)

Lurasidon (Latuda)

Methylphenidate (Ritalin, Metadate, Concerta, Daytrana, Focalin)

Mirtazapine (Remeron)

Nefazodone (Serzone)

Nortriptyline (Pamelor)

Olanzapine (Zyprexa)

Oxcarbazepine (Trileptal)

Paliperidon (Invega)

Valproic Acid (Depakote, Depakene)

Venlafaxine (Effexor, Pristiq)

Zaleplon (Sonata)

Ziprasidone (Geodon)

Zolpidem (Ambien)

No Medication

Other

Who initially prescribed your child's medication?

Neurologist

Psychiatrist

Pediatrician

Psychologist

Psychiatric Nurse

Primary Care Physician

Not Applicable

Other

Who currently provides refill prescriptions for your child’s medication?

Neurologist

Psychiatrist

Pediatrician

Psychologist

Psychiatric Nurse

Primary Care Physician

Therapist

Social Worker

Counselor

Case Manager

Not Applicable

Other

My child currently is involved in and/or receives services from the following systems

(please indicate one or more):

Mental Health

Perform Care

Child Welfare DCP&P (DYFS)

Juvenile Justice

Unified Care Management Organization (UCM)

Care Management Organization (CMO)

Youth Case Management (YCM)

Mobile Response & Stabilization Services (MRSS)

Family Support Organization (FSO)

Private Mental Health Provider

Family Success Center

Social Services / Welfare / TANF

Special Education

Developmental Disabilities

Other

N/A

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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