Csa.virginia.gov
Family Needs Assessment Survey
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Demographics
| | 20% |
This survey is to gather information. re: Virginia's current Service Delivery System. Your answers to these questions will help state and local agencies understand what families need in terms of services and assistance. If you have more than one child receiving services, you will have the option to report on each child within the survey. Thank you in advance for your much needed help.
1. Name (Individual completing the survey)
[pic]
Name (Individual completing the survey)
2. County/City
| |A-C |D-I |J-O |P-S |T-Z |
|County/City |[pic] |[pic] |[pic] |[pic] |[pic] |
| |County/City County/City A-C |D-I |J-O |P-S |T-Z |
*
3. Child Age
|[pic][pic]Child Age 0-3 |[pic][pic]11-13 |[pic][pic]19-21 |
|[pic][pic]4-10 |[pic][pic]14-18 |[pic][pic]21 + |
*
4. Gender
|[pic][pic]Gender Male |
|[pic][pic]Female |
*
5. Ethnic Background (select all that apply)
|[pic][pic]Ethnic Background (select all that apply) African American |
|[pic][pic]Asian |
|[pic][pic]Bi-Racial |
|[pic][pic]Caucasian |
|[pic][pic]Hispanic |
|[pic][pic]Native American |
|[pic][pic]Other |
|Other (please specify)[pic] |
6. Diagnosis/Condition
[pic]
Diagnosis/Condition
Family Needs Assessment Survey
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What is your impression on the quality of services you are receiving?
| | 40% |
*
1. What type of services are you currently receiving through an IEP? (Select all that apply)
|[pic][pic]What type of services are you currently|[pic][pic]Individual,group, family |[pic][pic]School-based services |
|receiving through an IEP? (Select all that apply)|therapy |[pic][pic]Substance abuse services |
| - Do not have an IEP |[pic][pic]Intensive in-home services |[pic][pic]Summer child care |
|[pic][pic]After school services |[pic][pic]Medical management |[pic][pic]Supervised |
|[pic][pic]Behavioral aides |[pic][pic]Mentoring |social/recreational services |
|[pic][pic]Case management |[pic][pic]Private Day |[pic][pic]Therapeutic day treatment |
|[pic][pic]Crisis intervention/stabilization |Placement/Private School |[pic][pic]Vocational services |
|[pic][pic]Family support/education |[pic][pic]Residential Services | |
|[pic][pic]Independent living services |[pic][pic]Respite care | |
|Other (please specify)[pic] |
*
2. What type of services are you currently receiving in the home/community? (Select all that apply)
|[pic][pic]What type of services are you currently|[pic][pic]Individual,group, family |[pic][pic]Substance abuse services |
|receiving in the home/community? (Select all that|therapy |[pic][pic]Summer child care |
|apply) - Do not receive services in |[pic][pic]Intensive in-home services |[pic][pic]Supervised |
|home/community |[pic][pic]Medical management |social/recreational services |
|[pic][pic]After school services |[pic][pic]Mentoring |[pic][pic]Therapeutic day treatment |
|[pic][pic]Behavioral aides |[pic][pic]Residential Services |[pic][pic]Vocational services |
|[pic][pic]Case management |[pic][pic]Respite care | |
|[pic][pic]Crisis intervention/stabilization |[pic][pic]School-based services | |
|[pic][pic]Family support/education | | |
|[pic][pic]Independent living services | | |
*
3. Were the services available when you needed them?
|[pic][pic]Were the services available when you needed them? Yes |
|[pic][pic]No |
|[pic][pic]N/A |
|If no, why not ?(please specify)[pic] |
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4. Were the services affordable?
|[pic][pic]Were the services affordable? Yes |
|[pic][pic]No |
|[pic][pic]N/A |
|If no, why not? (please specify)[pic] |
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5. How was the service(s) funded? (Select all that apply)
|[pic][pic]How was the service(s) funded? (Select all that apply) Private (Private Insurance, Private Provider) |
|[pic][pic]Public (Medicaid, CSB, FAPT, CSA) |
|[pic][pic]Out of pocket |
6. Has your family experienced any of these challenges related to a child with special health care needs? (Select all that apply)
|[pic][pic]Has your family experienced any |[pic][pic]Extra burden on family members |[pic][pic]Marital or relationship issues |
|of these challenges related to a child |and/or extended family |with significant other |
|with special health care needs? (Select |[pic][pic]Extra burden on friends |[pic][pic]Others |
|all that apply) Loss of job |[pic][pic]"Case managing" your child with | |
|[pic][pic]Change in career |special health care needs | |
|[pic][pic]Loss of insurance |[pic][pic]Extra stress on the family | |
|[pic][pic]Loss of or change in insurance's| | |
|benefits | | |
|Other (please specify)[pic] |
*
7. How has your child benefited from services received? (Select all that apply)
|[pic][pic]How has your child benefited from services received? (Select all that apply) Is showing less stress |
|[pic][pic]Is more likely to participate in community activities |
|[pic][pic]Is doing better in school |
|[pic][pic]Other |
|Other (please specify)[pic] |
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8. How has your family benefited from services received?(Select all that apply)
|[pic][pic]How has your family benefited from services received?(Select all that apply) Less stress in home |
|[pic][pic]Better able to participate in community activities |
|[pic][pic]Other |
|Other[pic] |
9. Do you have an additional child receiving services?
|[pic][pic]Do you have an additional child receiving services? Yes |
|[pic][pic]No |
Family Needs Assessment Survey
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Service and Involvement
| | 100% |
*
1. How can the quality of any of the services you receive be improved? If you do not have a response please enter NA.
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How can the quality of any of the services you receive be improved? If you do not have a response please enter NA.
*
2. If you have been dissatisfied with a provider's services, list ways you believe that provider could be more responsive to your needs. If you do not have a response please enter "n/a"
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If you have been dissatisfied with a provider's services, list ways you believe that provider could be more responsive to your needs. If you do not have a response please enter "n/a"
*
3. Mark the reasons you believe you were unable to receive the services you would like to receive, but did not.(Select all that apply)
|[pic][pic]Mark the reasons you believe you were unable to receive the services you would like to receive, but did not.(Select |
|all that apply) Lack of funding |
|[pic][pic]No provider |
|[pic][pic]Other |
|Other[pic] |
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4. Is there a service that you would like to receive that you currently do not receive? (Select all that apply)
|[pic][pic]Is there a service that you |[pic][pic]After School Activities |[pic][pic]Other |
|would like to receive that you currently |[pic][pic]Respite |[pic][pic]N/A |
|do not receive? (Select all that apply) | | |
|Day Treatment | | |
|[pic][pic]Child Psychiatrist | | |
|Other[pic] |
5. If you answered Question 4, please list any ideas/suggestions you may have that could help make those service(s) available to you.
[pic]
If you answered Question 4, please list any ideas/suggestions you may have that could help make those service(s) available to you.
6. Check all boxes that you would like more information about, or would like to get involved with. (Select all that apply)
|[pic][pic]Check all boxes that you would |[pic][pic]Legislative Issues |[pic][pic]Regional Meeting |
|like more information about, or would like |[pic][pic]Local Chapters/Support Group |[pic][pic]Local Meeting |
|to get involved with. (Select all that |[pic][pic]State Meeting |[pic][pic]Other |
|apply) Advocacy | | |
|[pic][pic]Family 2 Family Support | | |
|[pic][pic]Participate in training | | |
|Other (please specify)[pic] |
7. Barriers keeping you from being involved.(Select all that apply)
|[pic][pic]Barriers keeping you from being |[pic][pic]Locations of the meetings |[pic][pic]Angry/frustration with the system|
|involved.(Select all that apply) Child |[pic][pic]Lack of Knowledge |[pic][pic]Other |
|Care |[pic][pic]Lack of Voice | |
|[pic][pic]Transportation |[pic][pic]Not feeling valued | |
|[pic][pic]Funding | | |
|[pic][pic]Times of the meetings | | |
|Other (please specify)[pic] |
8. Contact information (Optional)
|Contact information |[pic] |
|(Optional) Name | |
|Email |[pic] |
|Telephone No. |[pic] |
9. Is there anything else you would like us to know?
Thank you for your time and participation.
[pic]
Is there anything else you would like us to know? Thank you for your time and participation.
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