APPENDIX A
QUESTIONNAIRES
APPENDIX A-1
QUESTIONNAIRE:
AGENCY/ORGANIZATION
EXECUTIVE DIRECTORS AND CHILDREN'S
MENTAL HEALTH COALITION
Children's Mental Health Study -- Agencies/Organizations
Sedgwick County November 2002
Please complete and return this survey to United Way of the Plains by: Wednesday, November 20, 2002
________________________________________________________________
YOUR AGENCY
1. Which of the following services does your agency/organization provide? (Circle "yes" or "no" for each service.)
a.
b.
c.
Attendant care (mental health)
Case management (mental health)
Respite care (mental health)
Yes
Yes
Yes
No
No
No
l.
m.
n.
Individual therapy
Job readiness
Family support
Yes
Yes
Yes
No
No
No
d.
e.
f.
Crisis attendant care
Crisis case management
Assessment and referral
Yes
Yes
Yes
No
No
No
o.
p.
q.
After-hours services/crisis services
Residential/group home
Therapeutic day school
Yes
Yes
Yes
No
No
No
g.
h.
i.
j.
k.
Psychological testing
Medication management
Family therapy
Group therapy
In-home therapy
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
r.
s.
t.
Partial hospitalization services
Yes
No
Psycho-social groups
Yes
No
Other services (Please specify.)
___________________ ______________________
___________________ ______________________
2. What ages does your agency/organization serve? (Circle "yes" or "no" for each age group.)
a. Birth through 4 years Yes
No
d. 12 through 17 years
Yes
No
b. 5 through 11 years
No
e. 18 years or older
Yes
No
Yes
3. a. Thinking of October 1, 2001 to September 30, 2002, how many children
younger than 18 years old did your agency/organization serve?
_____________ (Record number.)
(Please count each child only once.)
b. How many of these children reside in Sedgwick County?
c.
_____________ (Record number.)
In what other counties do these children reside? (Circle all that apply.)
1 -2 -3 -4 --
Only Sedgwick
Butler
Cowley
Harper
5 -6 -7 -8 --
Harvey
Kingman
Reno
Sumner
9 -- Other -- please specify:
___________________
___________________
___________________
4. How are children younger than 18 years old referred to your agency/organization?
____________________________________________________________________________________________
____________________________________________________________________________________________
5. a. Is there a waiting list for children to receive mental health services from your agency/organization?
1 -- Yes
2 -- No
9 -- Don't know
b. What is the duration of time between your agency's receiving an initial contact regarding a child and that child's
intake appointment, first therapy appointment, beginning of service, etc.?
____________________________________________________________________________________________
_____________________________________________________________________________________________
c. Is there a waiting list for mental health services for children your agency refers to another agency/organization?
1 -- Yes
2 -- No
Children's Mental Health Study (Agencies), November 2002
United Way of the Plains, Wichita, Kansas
9 -- Don't know
Page 1
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6. Do you have to turn away children who need services from your agency/organization?
1 -- Yes
2 -- No
IF YES: Why do you have to turn children away? ___________________________________________________________
_______________________________________________________________________________________________________
How many? _____________________________________________________________________________________________
_______________________________________________________________________________________________________
CHILDREN'S MENTAL HEALTH SERVICES - OVERALL
7. For Sedgwick County children younger than 18 years old, are you aware of any mental health services that are
lacking or any mental health needs that are unmet?
1 -- Yes
2 -- No
9 -- Don't know
Please provide a few comments to support your response.______________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
8. For Sedgwick County children ages 5 through 11 years old, are you aware of any inpatient mental health services
that are lacking or any inpatient mental health needs that are unmet? For our purposes, inpatient will mean a stay of
more than 48 hours.
1 -- Yes
2 -- No
9 -- Don't know
Please provide a few comments to support your response.______________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
9. a. Is there a shortage of mental health services for Sedgwick County children?
1 - Yes
2 - No
9 - Don't know
IF YES: Please describe the shortage.______________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
b. Are there overlaps in mental health services for Sedgwick County children?
1 - Yes
2 - No
9 - Don't know
IF YES: Please describe the overlaps.______________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
10. Who benefits from overstating children's mental health needs in Sedgwick County, and why?
_____________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
11. Who benefits from understating children's mental health needs in Sedgwick County, and why?
_____________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Children's Mental Health Study (Agencies), November 2002
United Way of the Plains, Wichita, Kansas
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12. If a child younger than 18 years old for which your agency/organization is responsible needs residential care, please
describe your options at present. __________________________________________________________________
_____________________________________________________________________________________________
13. In the following list of services, please rate how important each service is in meeting the mental health needs of
Sedgwick County children under 18 years old using a five-point scale where 1 is "not at all important" and 5 is "very
important." (Circle one number for each service.)
Not at all
Important
Services
Very
Important
Don't
Know
a.
Attendant care (mental health)
1
2
3
4
5
9
b.
Case management (mental health)
1
2
3
4
5
9
c.
Respite care (mental health)
1
2
3
4
5
9
d.
Crisis attendant care
1
2
3
4
5
9
e.
Crisis case management
1
2
3
4
5
9
f.
Assessment and referral
1
2
3
4
5
9
g.
Psychological testing
1
2
3
4
5
9
h.
Medication management
1
2
3
4
5
9
i.
Family therapy
1
2
3
4
5
9
j.
Group therapy
1
2
3
4
5
9
k.
In-home therapy
1
2
3
4
5
9
l.
Individual therapy
1
2
3
4
5
9
m.
Job readiness
1
2
3
4
5
9
n.
Family support
1
2
3
4
5
9
o.
After-hours services/crisis services
1
2
3
4
5
9
p.
Residential/group home
1
2
3
4
5
9
q.
Therapeutic day school
1
2
3
4
5
9
r.
Partial hospitalization services
1
2
3
4
5
9
s.
Psycho-social groups
1
2
3
4
5
9
14. From the list above, what are the five most important services in meeting the mental health needs of children under 18
years old? (Record letter from the services listed above; for example, record "f" for "assessment and referral," etc.)
Most important
2nd most important
3rd most important
4th most important
5th most important
15. A child day hospital program offers a place for treatment of children ages 5 through 11 years old that have
significant psychiatric symptoms requiring monitoring and treatment with the intensity of a day program (8:00 a.m. to
3:00 p.m.) but not 24-hour care and that have an adequate support system outside of the hospital setting.
How do you see such a program complementing services your agency/organization provides?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Children's Mental Health Study (Agencies), November 2002
United Way of the Plains, Wichita, Kansas
Page 3
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16. An acute child psychiatric inpatient program offers 24-hour nursing care and multidisciplinary treatment for
children ages 5 through 11 years old with psychiatric conditions meeting medical necessity for this level of care.
Programming is structured for short-term acute stabilization (5 to 7 days) and return to community-based services.
a. Do you believe Wichita and the surrounding community could support an acute child psychiatric inpatient unit?
1 -- Yes
2 -- No
9 -- Don't know
b. What benefits do you see from having an acute child psychiatric inpatient unit in Sedgwick County, and why?
___________________________________________________________________________________________
___________________________________________________________________________________________
c.
What drawbacks do you see from having an acute child psychiatric inpatient unit in Sedgwick County, and why?
___________________________________________________________________________________________
___________________________________________________________________________________________
17. What -- if anything -- needs to be done to improve children's mental health services in Sedgwick County?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
18. I am:
1 -- Agency director, president, chief executive officer
2 -- Other (Specify.): _____________________
19. I have been with this agency for ___________ years overall and have worked in the Wichita/Sedgwick County area in
the health and human services field for _________ years.
20. If you wish, please identify the agency for which you are responding: ______________________________________
Thank you for your time. Your opinions are very important.
Your responses will remain anonymous and will be reported only in the aggregate.
Please return completed survey in the postage-paid, return reply envelope provided
to United Way of the Plains, 245 North Water, Wichita, Kansas 67202 by Friday, January 17, 2003.
If necessary, may a representative of United Way of the Plains' Community Planning and Resources department contact
you for additional information?
1 -- Yes
If Yes:
2 -- No
Name: ____________________________________________
Phone: ____________________________________________
Best time to contact:
Children's Mental Health Study (Agencies), November 2002
United Way of the Plains, Wichita, Kansas
_______________________________
Page 4
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APPENDIX A-2
QUESTIONNAIRE:
HEALTH CARE PROVIDERS
(PSYCHIATRISTS/PSYCHOLOGISTS)
Children's Mental Health Study -- Healthcare Providers
Sedgwick County October 2002
Please complete and return this survey to United Way of the Plains by: November 13, 2002
YOUR PRACTICE
1. Thinking of the past year (October 1, 2001 to September 30, 2002), did you treat the following diagnosis categories
for children's mental health in your practice?
(Circle "yes" or "no" for each diagnosis category.)
a.
Adjustment Disorder
Yes
No
j.
Mental Retardation
Yes
No
b.
Anxiety Disorder
Yes
No
k.
Oppositional Defiant Disorder
Yes
No
c.
Attention Deficit/ Hyperactivity Disorder
Yes
No
l.
Reactive Attachment Disorder
Yes
No
d.
Bipolar Disorder
Yes
No
m.
Schizophrenia/Psychosis
Yes
No
e.
Conduct Disorder
Yes
No
n.
Sleep Disorder
Yes
No
f.
Depression
Yes
No
o.
Substance-Related Disorder
Yes
No
g.
Developmental Disorder
Yes
No
Other: (Specify)
Yes
No
h.
Eating Disorder
Yes
No
p.
__________________________________
i.
Impulse Control Disorder
Yes
No
q.
__________________________________
2. From October 1, 2001 to September 30, 2002, what five diagnostic categories for children's mental health did you see
most often as a primary diagnosis in your practice? (From the list above, record letter from diagnostic category in
each box; for example, record "e" for "depression," etc.)
Saw most often
Saw 2nd most often
Saw 3rd most often
Saw 4th most often
3. a. Thinking of October 1, 2001 to September 30, 2002, how many
patients did you see who are younger than 18 years old?
b. How many of these patients reside in Sedgwick County?
c.
Saw 5th most often
_____________ (Record number.)
_____________ (Record number.)
In what other counties do your patients younger than 18 years old reside? (Circle all that apply.)
1 -2 -3 -4 -5 --
Only Sedgwick
Butler
Cowley
Harper
Harvey
6 -7 -8 -9 --
Kingman
Reno
Sumner
Other -- please specify:
____________________
____________________
4. Do you serve severely emotionally disturbed (SED) children as defined by state criteria?
1 -- Yes
2 -- No
3 -- Not familiar with state-defined SED criteria
(Circle response.)
9 -- Don't know
5. How are patients younger than 18 years old referred to your practice?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Children's Mental Health Study (Providers), November 2002
United Way of the Plains, Wichita, Kansas
Page 1
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CHILDREN'S MENTAL HEALTH SERVICES - FAMILIARITY
6. Please rate how familiar you are with the children's mental health services provided by the following facilities using
a five-point scale where 1 is “not at all familiar” and 5 is “very familiar.”
(Circle one number for each facility.)
Facilities for Children's
Mental Health Services
Not at All
Familiar
Very
Familiar
Don't
Know
Outpatient
a.
Catholic Charities Counseling Center
1
2
3
4
5
9
b.
COMCARE of Sedgwick County
1
2
3
4
5
9
c.
Counseling & Mediation Center
1
2
3
4
5
9
d.
Family Consultation Services
1
2
3
4
5
9
e.
University of Kansas School of Medicine - Wichita
1
2
3
4
5
9
f.
Via Christi – Good Shepherd Campus
1
2
3
4
5
9
g.
Wichita Child Guidance Center
1
2
3
4
5
9
Inpatient
h.
Coffeyville Regional Medical Center, Coffeyville
1
2
3
4
5
9
i.
Prairie View, Newton
1
2
3
4
5
9
j.
Rainbow State Hospital, Kansas City, KS
1
2
3
4
5
9
k.
St. Francis, Connecting Families Care Center, Topeka
1
2
3
4
5
9
l.
Stormont-Vail, Topeka
1
2
3
4
5
9
m.
University of Kansas School of Medicine - KC
1
2
3
4
5
9
n.
Via Christi – Good Shepherd Campus, Wichita
1
2
3
4
5
9
CHILDREN'S MENTAL HEALTH SERVICES - OVERALL
7. For Sedgwick County children younger than 18 years old, are you aware of any mental health services that are
lacking or any mental health needs that are unmet?
1 -- Yes
2 -- No
Please provide a few comments to support your response______________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
8. Is there a shortage of mental health services for children?
1 -- Yes
2 -- No
IF YES: For what services?______________________________________________________________________
_______________________________________________________________________________________________________
How large is the shortage?_____________________________________________________________________________
Children's Mental Health Study (Providers), November 2002
United Way of the Plains, Wichita, Kansas
Page 2
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9. Who benefits from overstating children's mental health needs in Sedgwick County, and why?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
10. Who benefits from understating children's mental health needs in Sedgwick County, and why?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
11. What -- if anything -- needs to be done to improve children's mental health services in Sedgwick County?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
CHILDREN'S MENTAL HEALTH SERVICES - OUTPATIENT
Please focus on outpatient mental health services available for Sedgwick County children ages 5 through 11 years.
12. a. Within the past year (October 1, 2001 to September 30, 2002) have you had any difficulty accessing outpatient
mental health services on referrals you have made?
1 -- Yes
2 -- No (Skip to Q13.)
b. IF YES: Please describe any difficulties you have experienced accessing outpatient services on referrals for
children's mental health.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
c.
What is your patients' wait time for services? (Please specify whether your answer pertains to patients' wait time
for your own practice, patients' wait time for another agency when you make a referral, etc.)
_______________________________________________________________________________________________________
d.
What is the duration of time between a patient's initial call and the intake appointment or first therapy appointment?
_______________________________________________________________________________________________________
CHILDREN'S MENTAL HEALTH SERVICES - INPATIENT
Now let’s focus on inpatient mental health services available for Sedgwick County children ages 5 through 11 years.
For our purposes, inpatient will mean a stay of more than 48 hours.
13. a. Within the past 12 months (October 1, 2001 to September 30, 2002), have you referred one or more children
ages 5 through 11 years old for inpatient psychiatric treatment?
1 -- Yes
2 -- No (Skip to Q15.)
b. Approximately how many children ages 5 through 11 years old
have you referred during this period?
_____________ (Record number.)
Children's Mental Health Study (Providers), November 2002
United Way of the Plains, Wichita, Kansas
Page 3
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14. In the following table, please indicate whether you currently refer children ages 5 through 11 years old for inpatient
admission for mental health needs; that is, a stay of more than 48 hours.
(Circle "yes" or "no" for each facility.)
For facilities to which you do refer, please estimate the number of Sedgwick County children ages 5 through 11 years
old you referred between October 1, 2001 and September 30, 2002 for inpatient admission for mental health needs.
Currently Refer to
(Inpatient Mental
Health-Age 5-11)
Facilities for Children's Mental Health Services
(Inpatient)
# of Referrals
for Admission
(10/2001 to 9/2002)
a.
None - don’t refer for inpatient mental health
Yes
b.
Coffeyville Regional Medical Center
Yes
No
________
c.
Prairie View, Newton
Yes
No
________
d.
Rainbow State Hospital, Kansas City, KS
Yes
No
________
e.
St. Francis, Connecting Families Care Center,
Topeka
Yes
No
________
f.
Stormont-Vail, Topeka
Yes
No
________
g.
University of Kansas School of Medicine - KC
Yes
No
________
Other: Facility:
(Skip to Q15.)
Location:
h.
______________________ __________________
Yes
________
i.
______________________ __________________
Yes
________
j.
______________________ __________________
Yes
________
Total admissions:
________
(Note: Total should equal your answer in Q13b.)
15. For Sedgwick County children ages 5 through 11 years old, are you aware of any inpatient mental health services
that are lacking or any inpatient mental health needs that are unmet?
1 -- Yes
2 -- No
9 -- Don't know
Please provide a few comments to support your response______________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
16. Thinking about the number of children ages 5 through 11 years old that you referred for inpatient psychiatric treatment
within the past 12 months (October 1, 2001 to September 30, 2002), if the child inpatient facility had been located in
Wichita, would you have: (Circle response.)
1
2
3
9
-----
Referred more patients
Referred the same number of patients
Referred fewer patients
Don't know
Children's Mental Health Study (Providers), November 2002
United Way of the Plains, Wichita, Kansas
Page 4
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17. A child day hospital program offers a place for treatment of children ages 5 through 11 years old that have
significant psychiatric symptoms requiring monitoring and treatment with the intensity of a day program (8:00 a.m. to
3:00 p.m.) but not 24-hour care and that have an adequate support system outside of the hospital setting.
a. If there had been a child day hospital program in Wichita during the past year,
approximately how many children would you have referred to it?
________ (Record number.)
b. What factors would influence your decision whether or not to refer patients there? (Assume it is fully licensed and
accredited.)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
18. An acute child psychiatric inpatient program offers 24-hour nursing care and multidisciplinary treatment for
children ages 5 through 11 years old with psychiatric conditions meeting medical necessity for this level of care.
Programming is structured for short-term acute stabilization (5 to 7 days) and return to community-based services.
Do you believe Wichita and the surrounding community could support a acute child psychiatric inpatient unit?
1 -- Yes
2 -- No
9 -- Don't know
Please provide a few comments to support your response______________________________________________
_______________________________________________________________________________________________________
ACCESS TO RESOURCES
19. For continuity of care for all Sedgwick County children younger than 18 years old with mental health needs, do you
believe there is adequate:
(Circle response.)
a.
b.
c.
Attendant care
Case management
Respite care
Yes
Yes
Yes
No
No
No
Don't know
Don't know
Don't know
d.
e.
f.
Crisis attendant care
Crisis case management
Assessment and referral
Yes
Yes
Yes
No
No
No
Don't know
Don't know
Don't know
g.
h.
I.
Psychological testing
Medication management
Family therapy
Yes
Yes
Yes
No
No
No
Don't know
Don't know
Don't know
j.
k.
l.
Group therapy
In-home therapy
Individual therapy
Yes
Yes
Yes
No
No
No
Don't know
Don't know
Don't know
m.
n.
o.
p.
Job readiness
Family support
After-hours services/crisis services
Residential group home
Yes
Yes
Yes
Yes
No
No
No
No
Don't know
Don't know
Don't know
Don't know
20. At present, five of these services -- case management, respite care, crisis attendant care and crisis case management
-- are tied to only severely emotionally disturbed (SED) patients as defined by state criteria. Should these be available
to all children with mental health needs?
1 -- Yes
2 -- No
3 -- Not familiar with state-defined SED criteria
9 -- Don't know
Please provide a few comments to support your response______________________________________________
_______________________________________________________________________________________________________
Children's Mental Health Study (Providers), November 2002
United Way of the Plains, Wichita, Kansas
Page 5
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21. Within the past year (October 1, 2001 to September 30, 2002), have you used a hospital emergency room as a
referral for a children's mental health patient because you did not know where else to refer the patient?
1 -- Yes
2 -- No
9 -- Don't know
SUMMARY
22. Are you aware of any redundant programs serving children's mental health needs in the community?
1 -- Yes
2 -- No
9 -- Don't know
Please provide a few comments to support your response.______________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
23. Do you have any additional comments or suggestions to offer concerning children's mental health services in
Sedgwick County?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
24. I am:
1 -- A psychiatrist 2 -- A psychologist
3 -- Other (Specify.): ___________________
25. I have been practicing for ___________ years overall and for _________ years in the Wichita/Sedgwick County area.
26. I serve clients through: (Mark all that apply.)
____
a. Behavioral Medicine Specialist
____
k.
UKSM - Wichita
____
b. Catholic Charities Counseling Center
____
l.
Via Christi-Behavioral Health Services
____
c. Center for Human Development
____
m. Wesley Clinic
____
d. Class - Case Management
____
n.
Wichita Child Guidance Center
____
e. COMCARE of Sedgwick County
____
o.
Wichita Growth Center
____
f. Counseling & Mediation Center
____
p.
Wichita Psychiatric Consultants
____
g. Family Consultation Services
____
q.
Other (Please specify: )
____
h. Family Psychological Group
__________________________
____
i. Prairie View
__________________________
____
j. Ruthven Group
__________________________
Thank you for your time. Your opinions are very important.
Your responses will remain anonymous and will be reported only in the aggregate.
Please return completed survey in the postage-paid, return reply envelope provided
to United Way of the Plains, 245 North Water, Wichita, Kansas 67202 by
_____________________.
If necessary, may a representative of United Way of the Plains' Community Planning and Resources department contact
you for additional information?
1 -- Yes
2 -- No
If Yes:
Name: ________________________________ Phone: _________________________
Best time to contact:
Children's Mental Health Study (Providers), November 2002
United Way of the Plains, Wichita, Kansas
___________________
Page 6
APPENDIX A-3
QUESTIONNAIRE:
SCHOOL STAFF
PUBLIC, PRIVATE AND
RELIGIOUS-BASED SCHOOLS
Children's Mental Health Study -- Schools
Sedgwick County March 2003
Please complete and return this survey by:
Wednesday, April 16, 2003
1. I am primarily a/an: (Circle one response.)
1 -- Classroom teacher
2 -- School counselor
3 -- School nurse
4 -- School psychologist
5 -- School social worker
6 -- Principal/vice principal
2.
I am primarily associated with a:
(Circle one response.)
3.
I am primarily associated with: (Circle one response.)
1 -2 --
1 -- Preschool
2 -- Elementary school
4.
Public school
Private school
7 -- Administrator (district)
8 -- Other (Specify: )
_____________________________
3 -4 --
Religious-based school
Other: (Specify: ) __________________
3 -- Middle school
4 -- High school
5 -- Other school (Specify:)
_____________________________
a.
I have been at my current assignment
_______
years
b.
I have been employed in the education field for
_______
years
5. a. Compared to five years ago, would you say classroom behavior issues have gotten better, gotten worse, or
stayed about the same?
1 - Gotten better
2 - Gotten worse
3 - Stayed the same
8 - Not in education 5 years ago
b. Compared to three years ago, would you say classroom behavior issues have gotten better, gotten worse, or
stayed about the same?
1 - Gotten better
c.
2 - Gotten worse
3 - Stayed the same
8 - Not in education 3 years ago
Compared to last year, would you say classroom behavior issues have gotten better, gotten worse, or stayed
about the same?
1 - Gotten better
2 - Gotten worse
3 - Stayed the same
8 - Not in education last year
6. a. Based on your experience, please rate the counseling, guidance and mental health services available to students
in Sedgwick County as a whole, using a five-point scale where 1 is "not at all satisfactory" and 5 is "very
satisfactory." (Circle one number.)
Not at All
Satisfactory
1
Very
Satisfactory
2
3
4
5
Don't
Know
9
b. Why do you say that?________________________________________________________________________
_______________________________________________________________________________________________________
7. a. Based on your experience, please rate the counseling, guidance and mental health services available to students
in your school district, using a five-point scale where 1 is "not at all satisfactory" and 5 is "very satisfactory."
(Circle one number.)
Not at All
Satisfactory
1
Very
Satisfactory
2
3
4
5
Don't
Know
9
b. Why do you say that?________________________________________________________________________
_______________________________________________________________________________________________________
Children's Mental Health Study (Schools), March 2003
United Way of the Plains, Wichita, Kansas
Page 1
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8. If you observed a student and believed he or she might benefit from some type of counseling, therapy or mental
health services, what steps would to you take for this student and his/her family?
1.
_____________________________________________________________________________
2.
_____________________________________________________________________________
3.
_____________________________________________________________________________
4.
_____________________________________________________________________________
9. What mental health resources do you feel would have the most significant positive impact on a student's behavior?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
10. Please rate your level of knowledge concerning what is available in the way of children's mental health services in
Sedgwick County using a five-point scale where 1 is "low knowledge of what is available" and 5 is "high knowledge of
what is available." (Circle one number.)
Low Knowledge of
What is Available
1
High Knowledge of
What is Available
2
3
4
5
Don't
Know
9
11. Please rate your level of knowledge concerning how to access available services for children's mental health in
Sedgwick County using a five-point scale where 1 is "low knowledge of how to access available services" and 5 is
"high knowledge of how to access available services." (Circle one number.)
Low Knowledge of
How to Access
1
High Knowledge of
How to Access
2
3
4
5
Don't
Know
9
12. a. We know that many students exhibit signs of isolation, sadness or depression. At what point would such behavior
become serious enough that you would suggest the student might benefit from mental health evaluation/services
either within or outside the school system?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
b. Students also exhibit refusal to cooperate, pay attention or follow directions. At what point would such behavior
become serious enough that you would suggest the student might benefit from mental health evaluation/services
either within or outside the school system?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
c.
Students also exhibit frequent lying, stealing or age-inappropriate behavior. At what point would such behavior
become serious enough that you would suggest the student might benefit from mental health evaluation/services
either within or outside the school system?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Children's Mental Health Study (Schools), March 2003
United Way of the Plains, Wichita, Kansas
Page 2
Continue on next page
&
d. And finally, some students threaten harm to themselves or others. At what point would such behavior become
serious enough that you would suggest the student might benefit from mental health evaluation/services either
within or outside the school system?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
13. Does your school have a policy that dictates when you can suggest a student might benefit from counseling,
guidance or mental health services?
1 -- Yes
2 -- No
9 -- Don't know
14. a. Within the past three years, have you ever suggested that a student might benefit from counseling, guidance or
mental health services, either within or outside the school system?
1 -- Yes (Go to part b)
2 -- No (Go to Q 15)
9 -- Don't know (Go to Q 15)
b. IF YES: Were these mental health services/evaluations provided:
1
2
3
9
-----
By school support staff (school social workers, counselor services, etc.)
By outside mental health services
By both types of services -- school support staff and outside mental health services
Don't know
15. a. Within the past three years, have you believed a student might benefit from counseling, guidance or mental
health services, but not suggested such services?
1 -- Yes (Go to part b)
2 -- No (Go to Q 16)
9 -- Don't know (Go to Q 16)
b. IF YES: What kept you from suggesting services?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
16. a. Within the past three years, have you contacted a hospital or inpatient treatment facility directly, on behalf of your
students?
1 - Yes (Go to part b)
2 - No (Go to Q 17)
3 - No, never had the need (Go to Q 17)
9 - Don't know (Go to Q 17)
b. IF YES: For what issues have you contacted a hospital or inpatient treatment facility directly?
(i.e., suicidal issues, homicidal issues, rape, abuse issues)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
17. a. Within the past three years, have you contacted an emergency room or hospital on behalf of your students
because you did not know who else to call?
1 - Yes (Go to part b)
2 - No (Go to Q 18)
3 - No, never had the need (Go to Q 18)
9 - Don't know (Go to Q 18)
b. IF YES: Was this because:
1 -- No service to meet needs was available. Please explain: _____________________________________
2 -- You did not know how to access a service. Please explain: ___________________________________
3 -- You did not know who to call. Please explain: ______________________________________________
8 -- Other. Please explain: ________________________________________________________________
Children's Mental Health Study (Schools), March 2003
United Way of the Plains, Wichita, Kansas
Page 3
Please turn page
&
18. Thinking about the school where you are assigned or spend the majority of your time, please rank the following six
items in terms of which would make the most positive change at your school, using "1" to represent the most
positive change, "2" to represent the second most positive change, etc.
(When you are done, you should have one "1," one "2," one "3," one "4," one "5" and one "6" -- not six "1" 's.)
_____
a. Add a teacher full-time to reduce class size.
_____
b. Add a teacher full-time to expand the curriculum base, increase ability to offer new classes.
_____
c. Add a mental health professional full-time to deal with counseling, referrals, anger management, etc.
_____
d. Add a paraprofessional full-time to assist in the classroom.
_____
e. Add a paraprofessional full-time to assist with lunchroom/playground duties, test monitoring, etc.
_____
f.
Have Community Mental Health Center staff available on campus (like Campus Connections)
g. Why did you rank your #1 choice as representing the most positive change?____________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
19. For Sedgwick County children younger than 18 years old, are you aware of any mental health services that are
lacking or any mental health needs that are unmet?
1 -- Yes
2 -- No
9 -- Don't know
Please provide a few comments to support your response.______________________________________________
_______________________________________________________________________________________________________
20. Are you aware of any duplication of mental health services for Sedgwick County children?
1 -- Yes
2 -- No
9 -- Don't know
Please provide a few comments to support your response.______________________________________________
_______________________________________________________________________________________________________
21. What -- if anything -- needs to be done to improve children's mental health services in Sedgwick County?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
THINKING ABOUT THE BUILDING TO WHICH YOU ARE ASSIGNED OR SPEND THE MAJORITY OF YOUR TIME:
22. a. How many days per week does your building have each of the following?
1. School counselor
__________ days
3. School psychologist
__________ days
2. School nurse
__________ days
4. School social worker
__________ days
b. In what ZIP code is your school building located?
_____________ (Record ZIP code.)
23. CLASSROOM TEACHERS ONLY: What is your average class size?
_____ (Record number of students.)
Thank you for your time. Your opinions are very important.
Your responses will remain anonymous and will be reported only in the aggregate.
Please return your completed survey by Wednesday, April 16, 2003, to Janet Symes, secretary; Psychological
Services Department; AMAC or mail to United Way of the Plains, 245 North Water, Wichita, Kansas 67202.
Children's Mental Health Study (Schools), March 2003
United Way of the Plains, Wichita, Kansas
Page 4
APPENDIX A-4
QUESTIONNAIRE:
PARENTS AND GUARDIANS
WHOSE CHILDREN ATTEND PUBLIC,
PRIVATE AND RELIGIOUS-BASED SCHOOLS
(ENGLISH AND SPANISH QUESTIONNAIRES)
Community Health Study -- Parents/Guardians
Sedgwick County November 2003
Please complete and return this survey to United Way of the Plains by:
1. a. How many children in your household are 18 years old or younger?
November 26, 2003
__________ children
(IF NONE: Skip to Question 14.)
b. Do these children attend: (Mark all that apply.)
1 -- Public schools
2 -- Private schools
c.
d.
3 -- Religious-based schools
4 -- Other (Specify: _________________________________)
For the 2003/2004 school year, what grades are your children in? (Circle all that apply.)
Pre-Kindergarten
3rd
7th
11th
Kindergarten
4th
8th
12th
1st
5th
9th
Other:
2nd
6th
10th
________________________
Besides your children, are you the legal guardian of any children younger
than 18 years old living in your household?
1 - Yes
2 - No
e.
Are any of the children in your household foreign exchange students?
1 - Yes
2 - No
f.
Are any of the children in your household placed there through foster care?
1 - Yes
2 - No
2. a. Based on your experience, please rate the counseling, guidance and mental health services available to
children in your school, using a five-point scale where 1 is "not at all satisfactory" and 5 is "very
satisfactory." (Circle one number.)
Not at All
Satisfactory
1
2
3
4
Very
Satisfactory
Don't
Know
5
9
b. Why did you rate it this way? ____________________________________________________________
___________________________________________________________________________________________
3. a. Based on your experience, please rate the counseling, guidance and mental health services available to
all children in Sedgwick County, using a five-point scale where 1 is "not at all satisfactory" and 5 is
"very satisfactory." (Circle one number.)
Not at All
Satisfactory
1
2
3
4
Very
Satisfactory
Don't
Know
5
9
b. Why did you rate it this way? ___________________________________________________________
___________________________________________________________________________________________
4. a. Within the past 12 months, have you had serious concerns that
your child might have mental health problems or might benefit
from counseling, guidance or mental health services?
1 - Yes
2 - No
9 - Don't know
b. IF YES: What behaviors caused those concerns?_________________________________________
_______________________________________________________________________________
Community Health Study (Parents/Guardians), Nov. 2003
United Way of the Plains, Wichita, Kansas
Page 1
Please turn page
&
5. a. What counseling, guidance and mental health services are you aware of that your child's school has?
___________________________________________________________________________________
____________________________________________________________________________________________
b.
In your opinion, does your child's school have adequate
counseling, guidance and mental health services?
1 - Yes
2 - No
9 - Don't know
c.
Would you use these services if you identified a need for your child?
1 - Yes
2 - No
9 - Don't know
d.
Would you use these services if school staff identified a need
for your child?
1 - Yes
2 - No
9 - Don't know
e.
If you or school staff identified a need for your child but you would not use your child's school's services,
what would keep you from using those services? ____________________________________________
___________________________________________________________________________________
6.
Within the past three years, has your child received any counseling,
guidance or mental health services through his/her school?
1 - Yes
2 - No
9 - Don't know
7. a. What counseling, guidance and mental health services are you aware of that are available in Sedgwick
County (both public and private) other than what is available through the schools?
____________________________________________________________________________________________
____________________________________________________________________________________________
b.
In your opinion, are adequate counseling, guidance and mental
health services available in Sedgwick County (both public
and private), other than what is available through the schools?
1 - Yes
2 - No
9 - Don't know
c.
Would you use these services if you identified a need for your child?
1 - Yes
2 - No
9 - Don't know
d.
Would you use these services if school staff identified a need
for your child?
1 - Yes
2 - No
9 - Don't know
e.
If you or school staff identified a need for your child but you would not use Sedgwick County services
(either public or private), what would keep you from using those services?_________________________
___________________________________________________________________________________
8.
a.
Within the past three years, has your child received any counseling,
guidance or mental health services in Sedgwick County
(both public and private), other than through the schools?
b.
IF YES: Were these services provided through: (Circle all that apply.)
01 -Catholic Charities
02 -COMCARE mental health services
03 -Family Consultation Services
04 -Kansas Children's Service League
05 -Mental Health Association
06 -Prairie View
07 -United Methodist Youthville
08 -Via Christi Behavioral Health Services,
Good Shepherd Campus
09 -Wichita Child Guidance Center
Community Health Study (Parents/Guardians), Nov. 2003
United Way of the Plains, Wichita, Kansas
1 - Yes
2 - No
9 - Don't know
10 -Private practice (pediatrician/family doctor)
11 -Private practice (psychiatrist/psychologist)
12 -Religious or spiritual counseling
13 -Juvenile Justice system (court, detention
facility, Judge Riddel's Boys Ranch)
14 -Other (Please list.)
___________________________________
___________________________________
Page 2
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&
9. a. We know that many children exhibit signs of isolation, sadness or depression. At what point would such
behavior become serious enough that you would seek help for your child outside your family?
____________________________________________________________________________________________
____________________________________________________________________________________________
b.
Children also exhibit refusal to cooperate, pay attention or follow directions. At what point would such behavior
become serious enough that you would seek help for your child outside your family?
____________________________________________________________________________________________
____________________________________________________________________________________________
c.
Children also exhibit frequent lying, stealing or age-inappropriate behavior. At what point would such behavior
become serious enough that you would seek help for your child outside your family?
____________________________________________________________________________________________
____________________________________________________________________________________________
d.
And finally, some children threaten harm to themselves or others. At what point would such behavior become
serious enough that you would seek help for your child outside your family?
____________________________________________________________________________________________
____________________________________________________________________________________________
10. If you observed your child and believed he or she might benefit from some type of counseling, guidance or
mental health services, what steps would you take to obtain such services?
1.
_____________________________________________________________________________
2.
_____________________________________________________________________________
3.
_____________________________________________________________________________
4.
_____________________________________________________________________________
11. If you believed your child might benefit from some type of counseling, guidance or mental health services,
which statement best describes the extent to which your insurance company/provider would influence
your choice of services? (Circle one number.)
12 -.
3459-
I would be free to choose service for my child.
I would be free to choose service for my child within the limits of a health care plan.
My health care plan would determine which service my child could use.
My child's health insurance provider is Medicaid/HealthWave.
I don't have health care coverage.
Don't know
12. Within the past three years, have you taken a child to a hospital emergency room because:
a.
He/she had a medical emergency
1 - Yes
2 - No
9 - Don't know
b.
He/she had an emotional/behavioral crisis.
1 - Yes
2 - No
9 - Don't know
c.
He/she had a health situation that was not an emergency,
but your regular healthcare provider's office was not open.
1 - Yes
2 - No
9 - Don't know
d.
You needed help and did not know where else to go.
1 - Yes
2 - No
9 - Don't know
e.
What caused your trip to the emergency room? ___________________________________________
_________________________________________________________________________________
Community Health Study (Parents/Guardians), Nov. 2003
United Way of the Plains, Wichita, Kansas
Page 3
Please turn page
&
13. a. In what school district does your child/do your children attend? (Circle all that apply.)
1 -Wichita (USD 259)
6 -Haysville (USD 261)
11 --Catholic Diocese
2 -Cheney (USD 268)
7 -Maize (USD 266)
12 --Independent School
3 -Clearwater (USD 264)
8 -Mulvane (USD 263)
13 --Rainbows United
4 -Derby (USD 260)
9 -Renwick (USD 267)
88 --Other school (Please list.)
5 -Goddard (USD 265)
10 -Valley Center (USD 262)
______________________
b. Please circle any special education categories under which your child is/your children are identified.
(Circle all that apply.)
0 -NONE - Do not receive Special Ed services
9 -Other Health Impaired
10 -Orthopedic Impairment
1 -Autistic
5 -Gifted
11 -Severely Multiply Disabled
2 -Deaf/blind
6 -Hearing Impaired
12 -Traumatic Brain Injury
3 -Emotionally Disturbed
7 -Learning Disabilities
13 -Visually Impaired
4 -Early Childhood Special Ed
8 -Mental Retardation
88 -Other services (Please list.)
______________________
14. For Sedgwick County children younger than 18 years old, are you aware of any counseling, guidance or
mental health services that are lacking or any such mental health needs that are unmet?
1 -- Yes
2 -- No
9 -- Don't know
Please provide a few comments to support your response________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
15. Are you aware of any duplication of mental health services for Sedgwick County children?
1 -- Yes
2 -- No
9 -- Don't know
Please provide a few comments to support your response________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
16. Do you have any additional comments or suggestions to offer concerning children's counseling, guidance
and mental health services in Sedgwick County?
_____________________________________________________________________________________
_____________________________________________________________________________________
The following questions are to assure we have included the opinions of people who reflect the
community as closely as possible.
17. What is your gender:
1 -- Male
2 -- Female
18. In what ZIP code do you live?
________________
Thank you for your time. Your opinions are very important.
Your responses will remain anonymous and will be reported only in the aggregate.
Please return your completed survey in the postage-paid, return reply envelope provided
by November 26, 2003, to United Way of the Plains, 245 North Water Street, Wichita, Kansas 67202.
Community Health Study (Parents/Guardians), Nov. 2003
United Way of the Plains, Wichita, Kansas
Page 4
Community Health Study – Padres y Guardias
Condado de Sedgwick Noviembre 2003
Favor de completar esta encuesta y regrese a United Way of the Plains antes de:
26 de Noviembre del 2003
1. a. ¿Cuantos niños tiene en casa menores de 18 años?
__________ niños
(Si marcó cero: Salte a pregunta 14.)
b. Estos niños atienden: (Marcar todos que se apliquen.)
1 -- Escuelas públicas
2 -- Escuelas privadas
c.
d.
3 -- Escuelas religiosas
4 -- Otra (Lista: _________________________________)
¿Durante el año escolar 2003/2004, en cual grado estan sus niños? (Marcar todos que se apliquen.)
Pre-Kindergarten
3rd
7th
11th
Kindergarten
4th
8th
12th
1st
5th
9th
Otro:
2nd
6th
10th
________________________
¿Además de sus niños, tiene usted guárdia legal sobre otros niños menores de
18 años que viven en casa?
1 - Sí
2 - No
e.
¿Tiene usted estudiantes de intercambio en su casa?
1 – Sí
2 - No
f.
¿Tiene usted niños de acogia en su casa?
1 – Sí
2 - No
2. a. ¿En su experiencia previa, que ópina usted de los servicios de consejo y salud mental disponibles a
sus hijos en su escuela? Utilize la escala de 5 puntos, 1 para “no es satisfactorio” hasta 5 para “muy
satisfactorio”. (Marque un numero solamente)
No Es
Satisfactorio
1
2
3
Muy
Satisfactorio
No
Se
5
9
4
b. ¿Porque marcó de esta manera?_________________________________________________________
___________________________________________________________________________________________
3. a. ¿En su experiencia previa, que ópina usted de los servicios de asesoramiento, dirección, y salud
metnal disponibles a sus hijos en el condado de Sedgwick? Utilize la escala de 5 puntos, 1 para “no es
satisfactorio” hasta 5 para “muy satisfactorio”. (Marque un numero solamente)
No Es
Satisfactorio
1
2
3
Muy
Satisfactorio
No
Se
5
9
4
b. ¿Porque marcó de esta manera?___________________________________________________________
___________________________________________________________________________________________
4. a.
b.
Dentro de los 12 meses anteriores, usted ha tenido
preocupaciónes con sus hijos sobre su salud mental o que
servicios de asesoramiento, dirección, o salud mental puedan
tener beneficio para sus hijos?
1 - Sí
2 - No
9 – No Se
Si su respuesta fue Sí: Cúal compartamiento le da preocupación?________________________
________________________________________________________________________________
Community Health Study (Parents/Guardians), Nov. 2003
United Way of the Plains, Wichita, Kansas
Page 1
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&
5. a. ¿Cuales servicios de asesoramiento, dirección, o servicios de salud mental, es usted consciente, son
ofrecidas en las escuela de sus niños?
___________________________________________________________________________________
____________________________________________________________________________________________
b.
¿En su opinión tienen las escuelas suficientes servicios
de asesoramiento, dirección, o servicios de salud mental?
c.
¿Utilazaría estos servicios si usted identificó un problema con sus
hijos?
d.
¿Utilizaría estos servicios si profesores de la escuela identifican
problemas con sus hijos?
e.
¿Si usted o un personal de la escuela identificara una necesidad de su niño per usted no utilizaria los
1 - Sí
2 - No
9 – No Se
1 – Sí
2 - No
9 – No Se
1 - Sí
2 - No
9 – No Se
servicios disponibles a través de la escuela, qúe le guardaría de usar esos servicios?
___________________________________________________________________________________
___________________________________________________________________________________
6.
¿En el plazo de los últimos tres años, su niño ha recibido asesoramiento,
dirección, o servicios médicos de salud mental a través de su escuela?
1 - Sí
2 - No
9 – No Se
7. a. ¿Cuales servicios de asesoramiento, dirección, o salud mental está usted enterado(a) que están
disponibles en el condado de Sedgwick (publico o privado) con excepción de los servicios que estan
disponibles a través de las escuelas?
____________________________________________________________________________________________
____________________________________________________________________________________________
b.
¿En su opinón, hay servicios adecuados sobre asesoramiento,
dirección, y salud mental disponibles en el condado de Sedgwick
(publico or privada) con excepción de servicios disponibles a través
de las escuelas?
c.
¿Utilizaría estos servicios si usted identificó un problema con sus
hijos?
d.
¿Utalizaría estos servicios si profesores de la escuela identifican
problemas con sus hijos?
e.
¿Si usted o un personal de la escuela identificara una necesidad de su niño pero usted no utilizara
1 - Yes
2 - No
9 - Don't know
1 - Yes
2 - No
9 - Don't know
1 - Sí
2 - No
9 – No Se
servicios del condado de Sedgwick (publico o privado), qué le guardaría de usar esos servicios?
___________________________________________________________________________________
___________________________________________________________________________________
8.
a.
¿En el plazo de los últimos tres años, su niño ha recibido servicios
de asesoramiento, dirección, o salud mental en el condado de
Sedgwick (publico o privado) con excepción de las escuelas?
Community Health Study (Parents/Guardians), Nov. 2003
United Way of the Plains, Wichita, Kansas
Page 2
1 - Yes
2 - No
9 - Don't know
Siguiente Página
&
b.
Si su respuesta fue Sí: Fueron estos servicios proporcionados a través:
01 -Catholic Charities
02 -COMCARE servicios de salud mental
03 -Family Consultation Services
04 -Kansas Children's Service League
05 -Mental Health Association
06 -Prairie View
07 -United Methodist Youthville
08 -Via Christi Behavioral Health Services,
Good Shepherd Campus
09 -Wichita Child Guidance Center
10 -Clinica Privada (Pediatra/Médico)
11 -Clinica Privada (Psiquiatra/Psicólogo)
12 -Consejo Espiritual/Religioso
13 -Sistema juvenil de la justicia (corte, facilidad
de la detención, Judge Riddel's Boys Ranch)
14 -Otro (Por favor ponga en lista)
___________________________________
___________________________________
9. a. Sabemos que muchos niños exhiben muestras del aislamiento, de la tristeza, o de la depresión. ¿En
que punto tal comportamiento llegara ser bastante serio que usted buscara ayuda para su niño fuera de
su familia?
____________________________________________________________________________________________
____________________________________________________________________________________________
b. Los niños también exhiben la denegación para cooperar, para prestar la atención o para seguir
direciones. ¿En que punto tal comportamiento llegara ser bastante serio que usted buscara ayuda para
su familia?
____________________________________________________________________________________________
____________________________________________________________________________________________
c.
Los niños también mostran la abilidad de mentir con frecuencia, robar o comportamiento que no es de
acuerdo con su edad. ¿En que punto tal comportamiento llegara ser bastante serio que usted buscara
ayuda para su niño fuéra de su familia?
____________________________________________________________________________________________
____________________________________________________________________________________________
d. Y finalmente, algunos niños amenazan daño a sí mismos o a otros. ¿En que punto tal comportamiento
llegara ser bastante serio que usted buscara ayuda para su niño fuera de su familia?
____________________________________________________________________________________________
____________________________________________________________________________________________
10. ¿Si usted observara a su niño y creyera que él o ella pueda ser que beneficie de un cierto tipo de
asesoramiento, de dirección, o de servicios médicos mentales, qué pasos usted tomaría para obtener tales
servicios?
1.
_____________________________________________________________________________
2.
_____________________________________________________________________________
3.
_____________________________________________________________________________
4.
_____________________________________________________________________________
Community Health Study (Parents/Guardians), Nov. 2003
United Way of the Plains, Wichita, Kansas
Page 3
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&
11. ¿Si usted creé que su niño/niña pueda beneficar de asesoramiento, dirección, o servicios médicos de salud
mental, cual declaración lo mas mejor posible descríbe el grado a el cual su seguro influenciaría su opcíon
de servicios? (Favor de marcar un numero solamente)
12 -.
3459-
Estaría libre elegir el servicio para mi niño.
Estaría libre elegir el servicio para mi niño dentro de los limites de mi plan de seguro medico.
Mi plan de seguro médico determinaría qué servicio podría utilizar mi niño.
Mi niño usa el seguro de Medicaid/HealthWave.
No tengo seguro médico.
No se
12. En el plazo de los últimos tres años, ha llevado a su niño/niña al hospital de emergencia porque:
a.
El/Ella tenía una emergencia médica.
1 - Sí
2 - No
9 – No Se
b.
El/Ella tenía un crisis emocional/de comportamiento.
1 - Sí
2 - No
9 – No Se
c.
El/Ella tenía una situación de la salud que no era una
1 - Sí
2 - No
9 – No Se
1 - Sí
2 - No
9 – No Se
emergencia, pero la oficina de su médico regular estaba cerrada.
d.
Usted necesitó ayuda y no sabía donde ir.
e.
¿Qué causó su viaje al cuarto de emergencia? __________________________________________
_________________________________________________________________________________
13. a. ¿Cual districto de escuela atiende su niño/niñas? (Marcar lo que sea aplicable)
1 -Wichita (USD 259)
6 -Haysville (USD 261)
11 --Catholic Diocese
2 -Cheney (USD 268)
7 -Maize (USD 266)
12 --Independent School
3 -Clearwater (USD 264)
8 -Mulvane (USD 263)
13 --Rainbows United
4 -Derby (USD 260)
9 -Renwick (USD 267)
88 --Otra Escuela (favor de escribir)
5 -Goddard (USD 265)
10 -Valley Center (USD 262)
______________________
b. Por favor marque las categorías de la educación especial bajo las cuales identifiquen a su niño/niños.
(Marcar lo que sea aplicable)
0 -Ninguno - No recive educación especial
9 -Otra debilitacíon de la salud
10 -Debilitacíon Ortopédica
1 -Autista
5 -Talentoso
11 -Gravemente Discapacitado
2 -Sordo/Siego
6 -Problema de oído
12 -Trauma del Cerebro
3 -Trastornos Mentales
7 -Dificultades de aprendizaje
13 -Vista detoriorada
4 -Early Childhood Special Ed
8 -Retraso Mental
88 -Otros servicios (Poner en lista)
______________________
14. ¿Para los niños del condado de Sedgwick más joven de 18 años de edad, es consciente usted de
asesoramiento, dirección o servicios de salud mental que hacen falta o necesidades para servicios de salud
mental que no se satisfacen?
1 -- Sí
2 -- No
9 -- No Se
Por favor de proveer sus comentarios para soportar su respuesta. _________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Community Health Study (Parents/Guardians), Nov. 2003
United Way of the Plains, Wichita, Kansas
Page 4
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&
15. ¿Está usted enterado de duplicación de los servicios médicos mentales para los niños del condado de
Sedgwick?
1 -- Sí
2 -- No
9 -- No Se
Por favor de proveer sus comentarios para soportar su respuesta. __________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
16. ¿Usted tiene comentarios o sugerencias adicionales a ofrecer referente el asesoramiento de los niños, la
dirección y a servicios médicos de salud mental en el condado de Sedgwick?
_____________________________________________________________________________________
_____________________________________________________________________________________
Las preguntas siguientes nos aseguran que hemos incluido las opiniones de la gente que
refleja a la comunidad lo mas cerca posible.
17. ¿Cuál es su género?
1 -- Varón
2 -- Mujer
18. ¿Cuál es su código postal? ________________
Gracias por su tiempo, sus opiniones son muy importante.
Sus respuestas seguirán siendo anonimas y serán divulgadas solamente en el agregado.
Por favor regrese su encuesta completa en el sobre pagado antes del 26 de Noviembre del 2003
a United Way of the Plains, 245 North Water Street, Wichita, Kansas 67202.
Community Health Study (Parents/Guardians), Nov. 2003
United Way of the Plains, Wichita, Kansas
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