1. Please answer the following to let us know a little about you.

Child's Gender

2. Child's Age

3. Race

4. For each item, circle the answer that matches your view:

Overall, I am satisfied with the services I received

5. I helped to choose my child s services

6. I helped to choose my child s treatment goals

7. The people helping my child stuck with us no matter what

8. I felt my child had someone to talk to when he/she was troubled

9. I participated in my child s treatment

10. The services my child and/or family received were right for us

11. The location of services was convenient for us

12. Services were available at times that were convenient for us

13. My family got the help we wanted for my child

14. My family got as much help as we needed for my child

15. Staff treated me with respect

16. Staff respected my family s religious/spiritual beliefs

17. Staff spoke with me in a way that I understood

18. Staff were sensitive to my cultural/ethnic background

19. As a Direct Result of Services my child and /or family received:

My child is better at handling daily life

20. My child gets along better with family members

21. My child gets along better with friends and other people

22. My child is doing better in school and/or work

23. My child is better able to cope when things go wrong

24. I am satisfied with our family life right now

25. My child is better able to do things he or she wants to do

26. As a Direct Result of Services my child and /or family received:
Please answer for relationships with persons other than your mental health provider

I know people who will listen and understand me when I need to talk

27. I have people that I am comfortable talking with about my child's problems

28. In a crisis, I would have the support I need from family or friends

29. I have people with who I can do enjoyable things

30. What has been the most helpful thing about the services you and your child received over the last 6 months?

31. What would improve the services here?

32. Please answer the following questions to let us know how your child is doing.

Is your child currently living with one or both parents?

33. Has your child lived in any of the following places in the last 6 months? (Check all that apply)

34. In the last year, did your child see a medical doctor (nurse) for a health check up or because he/she was sick? Check only one answer

35. Is your child on medication for emotional/behavioral problems?

36. If yes, did the doctor or nurse tell you what side effect to watch for?

37. Is your child still getting services from DMHSA?

38. How long did you receive services from DMHSA?

39. In the last month, did you get arrested by the police?

40. Was your child arrested since beginning to receive mental health services?

41. Since your child began to receive mental health services, have their encounter with the police…

42. Was your child expelled or suspended during the beginning of services?

43. Was you child expelled or suspended during the 12 months prior to that?

44. Since starting to receive services, the number of day my child was in school is:

45. Was your child arrested during the last 12 months?

46. Was you child arrested during the 12 months prior to that?

47. Over the last year, have your child's encounters with the police…

48. Was you child expelled or suspended during the 12 month prior to that?

49. Over the last year, the number of days my child was in school is