About You and Your School or Program

1. What is your current position? ____________________________________________

2. What is the age range of children and youth in your school or program(s)?
(If you are a parent of a child with emotional or behavioral problems, what is your child's age?)

3. Are there any special characteristics of the personnel or the children and youth in your school or program(s)?

4. How long have you held your current position?

5. Please list organizations to which you belong that help you work with children and youth with emotional or behavioral problems.

6. Please indicate specific areas of information you think would help you, or the people you work with, to be more effective and efficient in improving outcomes for children with emotional and behavioral problems. If you check or write in several information needs, please number them in terms of importance, with "1" indicating "most important."

Improving Children's Learning and Adjustment

Assessment

____ prereferral process
____ screening for potential emotional and behavioral problems
____ curriculum relevant assessment
____ ongoing assessment
____ measures of home environment
____ measures of community resources
____ other (specify):

Interventions

____ strategies to prevent emotional and behavioral problems
____ teaching social skills/problem solving
____ teaching cognitive skills
____ promoting social and emotional development
____ techniques for managing behavior problems in the classroom
____ medication
____ technology
____ child/youth counseling techniques
____ parent counseling
____ strategies to promote smooth transitions
____ engaging children and youth
____ other (specify:

7. Please indicate specific areas of information that would help you, or people you work with, to be more effective and efficient in working with families. If you check or write in several information needs, please number them in terms of importance, with "1" indicating "most important."

Working with Families

Practices

____ coordinating provider efforts and home efforts
____ establishing effective communication channels
____ connecting families to other service providers in the community
____ other (specify):

Special Families

____ working with culturally and linguistically diverse families
____ strategies for working with hard-to-reach families
____ other (specify):

Working with Other Professionals

8. Do you, or people you work with, 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."

____ mental health counselor
____ psychologist
____ behavior consultant/specialist/analyst
____ supervisor/administrator
____ social worker
____ technical assistance provider
____ probation officer/juvenile justice
____ professional libraries
____ professional conferences/workshops
____ resource centers
____ recreation and youth organizations
____ other (specify):

9. We are interested in knowing how, or from whom, you or people you work with get information about working with children with emotional and behavioral problems. Please rate on an ascending scale, with "1" being the "best source."

____ mental health counselor
____ general and/or special education teacher
____ school personnel
____ psychologist/psychiatrist
____ behavior consultant/specialist/analyst
____ social worker
____ families
____ probation officer/juvenile justice
____ supervisor/administrator
____ technical assistance provider
____ professional libraries
____ professional conferences/workshops
____ resource centers
____ other (specify:

10. For most of the people you work with, which of the following would be their preferred way(s) to receive information? If you check or write in several choices, please number them in terms of importance, with "1" indicating "most preferred."

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

• facility
• home
• other (specify):

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

11. Is there someone in your school, agency, program, or family organization whose job it is to give you such assistance?

• yes
• no
  

If yes, what is that person's title? ____________________________

12. Do you or most of the people you work with have access to the Internet?

• yes
• no
  

If yes, where?____________________

13. Do you have an E-mail address?

• yes
• no
  

Your address:_______________________

Barriers

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

15. 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

16. 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: ______________________________

17. 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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