About You and Your Child

1. What is your child's age?

2. Is your child being served in a:

• preschool
• regular class
• resource room
• special class within a regular school
• special class within a special school
• residential school
• other (specify):

3. What kind of emotional conditions or behavioral problems are you interested in receiving information about?

4. Please list any parent organizations to which you belong.

Helping My Child

5. Please indicate specific areas of information you think would help you to more effectively support your child. If you check or write in several information needs, please number them in terms of importance, with "1" indicating "most important."

____ techniques to manage behavior in various settings
____ discipline
____ helping with homework
____ medication and side effects
____ getting along with brothers or sisters
____ supports to enable my child to continue living at home, such as:

____ respite care
____ in-home therapy
____ Big Brother or Big Sister programs

____ other (specify):

Working with Schools

6. Please indicate specific areas of information that would help you to work more effectively with your child's school. If you check or write in several information needs, please number them in terms of importance, with "1" indicating "most important."

____ behavior management plan development
____ understanding educational test results
____ techniques to get involved or to stay involved in child's education
____ communicating with the school
____ choosing extra-curricular activities
____ my role in developing the IEP
____ monitoring IEP services
____ collaborating with the school
____ legal rights and responsibilities
____ suspension and expulsion issues
____ modified testing:

____ classroom tests
____ statewide tests

____ extended school year
____ other (specify):

Working with other Systems and Service Providers

7. Please indicate specific areas of information that would help you to work more effectively with other systems and with service providers. If you check or write in several information needs, please number them in terms of importance, with "1" indicating "most important."

____ identifying and connecting with parent support and advocacy groups
____ identifying and connecting with other service providers
____ choosing among different therapies and services
____ decisions about medications
____ accessing recreational opportunities
____ participating in community activities
____ becoming a more assertive and effective advocate for my child
____ what I should expect from providers and how should I expect to be treated
____ other (specify):

Other Information Needs

8. Please indicate other specific areas of information that would be of help to you. If you check or write in several information needs, please number them in terms of importance, with "1" indicating "most important."

____ understanding special education, mental health, and other systems and terminology
____ ensuring safe environments
____ dealing with residential schools
____ dealing with detention or corrections
____ how to become a better advocate
____ SSI/Medicaid benefits
____ how to affect policy decisions
____ life planning
____ legal issues (inheritance, guardianship)
____ vocational and independent living skills
____ other (specify):

9. Do you have access to any of the following resources for information? Use a scale of 1 to 3 to rate your ease of access, "1" being "very accessible" and "3" being "not very accessible."

____ another family
____ family support and advocacy organization
____ general education teachers
____ special education teachers
____ mental health counselor
____ social worker
____ probation officer
____ school administrator
____ school counselor
____ school psychologist
____ behavior consultant or specialist or analyst
____ libraries
____ conferences or workshops
____ other (specify):

10. Please indicate below how, or from whom, you get information about children with emotional and behavioral problems. If you indicate more than one, please rate your answers on an ascending scale, with "1" indicating "best source."

____ another family
____ family support and advocacy organizations
____ general education teachers
____ special education teachers
____ mental health counselor
____ social worker
____ probation officer
____ school administrator
____ school counselor
____ school psychologist
____ behavior consultant or specialist or analyst
____ libraries
____ conferences or workshops
____ other (specify):

11. In general, who has been most helpful to you in obtaining new information about working with your child? If you check or write in several resources please number them in terms of importance, with "1" indicating "most helpful."

____ another family
____ family support and advocacy organization
____ general education teachers
____ special education teachers
____ mental health counselor
____ social worker
____ probation officer
____ school administrator
____ school counselor
____ school psychologist
____ behavior consultant or specialist or analyst
____ libraries
____ conferences or workshops
____ other (specify):

Information Format

We understand that many of the traditional ways of distributing information to families often are not effective. Think of an example of information that you received recently that was helpful to you. What was it about that information that made it useful?

13. In what format was the information given to you?

____ informal discussions

____ with other families
____ with service providers (e.g., doctors, case workers)
____ other (specify):

____ workshop or conference
____ written materials
____ audio or video tapes
____ Internet
____ other (specify):

14. Which of the following would be your preferred way (s) to receive information? If you check or write in several choices, please number them in terms of importance, with "1" indicating the "most preferred."

____ Internet (i.e., listserv or E-mail), accessed from:

• home
• other (specify):

____ World Wide Web
____ postal service
____ 800 telephone number
____ demonstration site
____ videotapes
____ conference or workshop
____ computer disk
____ other (specify):

15. Do you have access to the Internet?

• yes
• no
  

If yes, where?____________________

16. Do you have an E-mail address?

• yes
• no
  

Your address:_______________________

17. Is there anything else about your information needs that you can tell us?

Barriers

18. Please name one major barrier to improving services for children and youth with emotional and behavioral problems and their families.

19. Thank you very much for taking your time to complete this Questionnaire. With your permission, may we keep you on our mailing list to receive updated information?

• yes
• no

20. Would it be acceptable for us to contact you in the future, if we have other questions?

• yes
• no

If yes, please record your name, address, and telephone number:

Name: ______________________________

Address:

___________________________________________________________

___________________________________________________________

___________________________________________________________

Telephone: ______________________________

21. Please check below if you would like a copy of our Center Information Booklet sent to you at the address above. Our booklet also is available here on our web site, where you can print out a copy for your personal use.

• Yes, please send me a Center Information Booklet.

If you need to reach us, our telephone number is 1-888/457-1551.

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