Form Approved OMB No: 0920-0445 Expiration Date: 10/31/2002 Mental Health and Social Services District Questionnaire Mental Health and Social Services District Questionnaire Questions Standard Mental Health and Social Services 1 - 23 Provision of Services 1 - 7 Student Assistance Programs 1 Individualized Education and Health Plans 2 - 3 Crisis Response Plan 4 Collaboration 5 - 6 Promotion 7 Evaluation 8 Staffing Characteristics 9 - 23 School-Based Health Center Services 24 Services Provided at Other Sites 25 - 29 Contracted Providers 25 - 26 Services 27 - 29 Mental Health and Social Services Coordinator 30 - 40 Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, Mailstop D-24, Atlanta, GA 30333; Attention PRA (0920-0445). Special Instructions 1. This questionnaire focuses on your district practices and policies. 2. When we use the word “policy,” we mean any mandate issued by the local school board or other local agency that affects mental health or social services in schools throughout your district. Please consider any policies officially adopted at the district level. These include policies developed by your district, or those based on model policies developed by your state or elsewhere. 3. We recognize that there may be some exceptions, but please answer the questions based on what is customary in your district. Please do not consider school practices or policies when answering the questions. (We will ask about school practices and policies when we collect information from schools across the country.) 4. If you would like more information about this study or would like clarification of any questions in this survey, please call Tim Smith at 1-800-647-9664, extension 6095. Standard Mental Health and Social Services 1. Has your district adopted a policy stating that Student Assistance Programs (SAPs) will be offered to all students? SAPs provide services designed to assist students experiencing personal or social problems that can impact school performance, physical health, or overall well-being. Yes 1 No 2 2. Has your district adopted a policy stating that school mental health or social services staff (e.g., guidance counselors, psychologists, or social workers) will participate in the development of Individualized Education Plans (IEPs), when indicated? Yes 1 No 2 3. Has your district adopted a policy stating that school mental health or social services staff will participate in the development of Individualized Health Plans (IHPs), when indicated? Yes 1 No 2 4. Has your district adopted a policy stating that schools will have a written plan describing their response to students’ mental health or social services needs after a crisis at school, such as a natural disaster or the death of a student or staff member? Yes 1 No 2 5. The following questions ask about standard mental health or social services, meaning those mental health or social services offered at the school, usually by a guidance counselor, psychologist, or social worker. By mental health and social services, we mean services such as crisis intervention, alcohol and other drug use treatment, or identification of or counseling for mental disorders or abuse. Later in the questionnaire, we will ask about any services offered by school-based health centers or at other sites. During the past 12 months, have district mental health or social services staff worked on mental health or social services activities with each of the following groups? Yes No a. District health education staff 1 2 b. District physical education staff 1 2 c. District food service staff 1 2 d. District health services staff 1 2 6. During the past 12 months, have district mental health or social services staff worked on mental health or social services activities with staff or members from each of these organizations? Yes No a. Local health department 1 2 b. Local hospital 1 2 c. Local mental health or social services agency 1 2 d. Health organization, such as the American Heart Association or the American Red Cross 1 2 e. Local colleges or universities 1 2 f. Local businesses 1 2 7. During the past 12 months, has your district done each of the following activities to promote the school mental health or social services program? Yes No a. Provided families with information on the school mental health or social services program 1 2 b. Met with a parents’ organization, such as the PTA, to discuss the mental health or social services program 1 2 c. Invited family members to tour the mental health or social services facilities 1 2 8. During the past 2 years, have the following aspects of your district mental health or social services program been evaluated? Yes No a. Use of the mental health or social services program 1 2 b. The quality of the school mental health or social services program 1 2 c. Student satisfaction with the school mental health or social services program 1 2 d. Family satisfaction with the school mental health or social services program 1 2 e. School mental health or social services policies 1 2 f. Mental health or social services staff development or in-service programs 1 2 9. Based on policies adopted by your district, what is the minimum level of education required for a newly-hired guidance counselor? If specific requirements are not described, please mark this box ? and skip to Question 10. Mark ? one box. Undergraduate degree in counseling 1 Undergraduate degree in some other field 2 Master’s degree in counseling 3 Master’s degree in some other field 4 Doctoral degree in counseling 5 Doctoral degree in some other field 6 Other degree 7 10. Has your district adopted a policy stating that a newly-hired guidance counselor will be licensed or certified by a state agency or board? If your state does not certify guidance counselors, please mark this box ? and skip to Question 11. Yes 1 No 2 11. Has your district adopted a policy stating that a newly-hired guidance counselor will be certified by the National Board of Certified Counselors? Yes 1 No 2 12. Based on policies adopted by your district, what is the minimum level of education required for a newly-hired psychologist? If specific requirements are not described, please mark this box ? and skip to Question 13. Mark ? one box. Undergraduate degree in psychology 1 Undergraduate degree in some other field 2 Master’s degree in psychology 3 Master’s degree in some other field 4 Doctoral degree in psychology 5 Doctoral degree in some other field 6 Other degree 7 13. Has your district adopted a policy stating that a newly-hired psychologist will be licensed or certified by a state agency or board? If your state does not certify psychologists, please mark this box ? and skip to Question 14. Yes 1 No 2 14. Has your district adopted a policy stating that a newly-hired psychologist will be certified by the National Association of School Psychologists? Yes 1 No 2 15. Based on policies adopted by your district, what is the minimum level of education required for a newly-hired social worker? If specific requirements are not described, please mark this box ? and skip to Question 16. Mark ? one box. Undergraduate degree in social work 1 Undergraduate degree in some other field 2 Master’s degree in social work 3 Master’s degree in some other field 4 Doctoral degree in social work 5 Doctoral degree in some other field 6 Other degree 7 16. Has your district adopted a policy stating that a newly-hired social worker will be licensed or certified by a state agency or board? If your state does not certify social workers, please mark this box ? and skip to Question 17. Yes 1 No 2 17. Has your district adopted a policy stating that a newly-hired social worker will have a School Social Work Specialist credential? Yes 1 No 2 18. Based on policies adopted by your district, what is the required student-to-staff ratio for the following types of staff? If your district has not adopted a policy, please mark the “No requirement” box. Students per No staff person requirement a. Guidance counselors _____ 1 b. Psychologists _____ 1 c. Social workers _____ 1 19. Based on policies adopted by your district, what is the required school-to staff ratio for the following types of staff? If your district has not adopted a policy, please mark the “No requirement” box. Schools per No staff person requirement a. Guidance counselors _____ 1 b. Psychologists _____ 1 c. Social workers _____ 1 20. Has your district adopted a policy stating that each school will have someone to oversee or coordinate mental health or social services at the school? Yes 1 No 2 21. During the past 2 years, has your district provided any funding for or offered staff development on each of the following topics to mental health or social services staff? This might include workshops, conferences, continuing education, graduate courses, or any other kind of in-service. Yes No a. Tobacco use cessation 1 2 b. Alcohol or other drug use treatment 1 2 c. Crisis intervention for personal problems 1 2 d. Identification of or counseling for mental or emotional disorders, such as anxiety or depression 1 2 e. Stress management 1 2 f. Eating disorders treatment 1 2 g. Identification of or referral for physical, sexual, or emotional abuse 1 2 h. Human immunodeficiency virus (HIV) testing and counseling 1 2 i. After-school programs such as day-care or supervised recreation 1 2 j. Services for gay, lesbian, or bisexual students 1 2 k. Child care options for teen mothers 1 2 l. Enrollment in Special Supplemental Food Program for Women, Infants, and Children (WIC) or accessing food stamps or food banks 1 2 m. Enrollment in Medicaid or the Children’s Health Insurance Program (CHIP) 1 2 n. Job readiness skills programs 1 2 22. During the past 2 years, has your district provided any funding for or offered staff development on each of the following topics to mental health or social services staff? Yes No a. Nutrition and dietary behavior counseling, including weight management 1 2 b. Eating disorders prevention 1 2 c. Physical activity and fitness counseling 1 2 d. Pregnancy prevention 1 2 e. HIV prevention 1 2 f. Sexually transmitted disease (STD) prevention 1 2 g. Suicide prevention 1 2 h. Tobacco use prevention 1 2 i. Alcohol or other drug use prevention 1 2 j. Violence prevention, for example bullying, fighting, or homicide 1 2 k. Accident or injury prevention 1 2 23. During the past 2 years, has your district provided any funding for or offered staff development on each of the following topics to mental health or social services staff? Yes No a. Case management for students with behavioral or social problems 1 2 b. Family counseling 1 2 c. Group counseling 1 2 d. Individual counseling 1 2 e. Comprehensive assessment or intake evaluation 1 2 f. Peer counseling or mediation 1 2 g. Self-help or support groups 1 2 School-Based Health Center Services 24. The next question asks about mental health and social services offered at school-based health centers — that is, health centers on school property where enrolled students can receive mental health and social services, including diagnostic and treatment services. These services are usually provided by a psychologist, social worker, or counselor, or other mental health or social services professional. Please do not include a traveling or mobile health center. Currently, how many school-based health centers offer mental health and social services to students in your district? _____ School-based health centers Services Provided at Other Sites 25. This next set of questions asks about mental health and social services delivered to students at other sites not on school property regardless of whether the services are paid for by the school system. These services may be provided by mental health and social services professionals who work at school-linked health centers or who have a contract, memorandum of agreement, or other similar arrangement with the district or school to provide mental health or social services to students. Currently, does your district have such arrangements to provide mental health or social services when needed to students in your district? Yes 1 No 2 ==> Skip to Question 30 26. Which of the following organizations or mental health or social services professionals have such arrangements with your district to provide mental health and social services to students when needed? Yes No a. School-linked health center 1 2 b. Local health department 1 2 c. Local hospital 1 2 d. Local mental health or social services agency 1 2 e. University or medical school 1 2 f. Managed care organization 1 2 g. Private psychologist 1 2 h. Private psychiatrist 1 2 i. Private social worker 1 2 j. Private counselor 1 2 27. Does your district have such arrangements with any organizations or mental health or social services professionals to provide each of the following mental health and social services to students when needed? Yes No a. Tobacco use cessation 1 2 b. Alcohol or other drug use treatment 1 2 c. Crisis intervention for personal problems 1 2 d. Identification of or counseling for mental or emotional disorders, such as anxiety or depression 1 2 e. Stress management 1 2 f. Eating disorders treatment 1 2 g. Identification of or referral for physical, sexual, or emotional abuse 1 2 h. HIV testing and counseling 1 2 i. Referrals for after-school programs such as day-care or supervised recreation 1 2 j. Services for gay, lesbian, or bisexual students 1 2 k. Referrals for child care for teen mothers 1 2 l. Assistance with enrolling in WIC or accessing food stamps or food banks 1 2 m. Assistance with enrolling in Medicaid or CHIP (Children’s Health Insurance Program) 1 2 n. Job readiness skills programs 1 2 28. Does your district have such arrangements with any organizations or mental health or social services professionals to provide each of the following services to students when needed in one-on-one or small group discussions? Yes No a. Nutrition and dietary behavior counseling, including weight management 1 2 b. Eating disorders prevention 1 2 c. Physical activity and fitness counseling 1 2 d. Pregnancy prevention 1 2 e. HIV prevention 1 2 f. STD prevention 1 2 g. Suicide prevention 1 2 h. Tobacco use prevention 1 2 i. Alcohol or other drug use prevention 1 2 j. Violence prevention, for example bullying, fighting, or homicide 1 2 k. Accident or injury prevention 1 2 29. Does your district have such arrangements with any organizations or mental health or social services professionals to provide each of the following mental health and social services to students as needed? Yes No a. Case management for students with behavioral or social problems 1 2 b. Family counseling 1 2 c. Group counseling 1 2 d. Individual counseling 1 2 e. Comprehensive assessment or intake evaluation 1 2 f. Peer counseling or mediation 1 2 g. Self-help or support groups 1 2 Mental Health and Social Services Coordinator 30. Currently, does someone in your district oversee or coordinate school mental health and social services? HEB003 Yes 1 No 2 ==> That is the last question. Thank you very much for taking the time to complete this questionnaire. 31. Are you this person? Yes 1 No 2 ==> That is the last question. Thank you very much for taking the time to complete this questionnaire. 32. Who do you work for? Mark ? all that apply. School district 1 Local health department 2 Local hospital 3 Local mental health or social services agency 4 University or medical school 5 Managed care organization 6 Other 7 33. Do you have an undergraduate degree? Yes 1 No 2 ==> That is the last question. Thank you very much for taking the time to complete this questionnaire. 34. What did you major in? Mark ? all that apply. Counseling 1 Psychology 2 Social work 3 Nursing 4 Health care administration 5 Biology or other science 6 Business 7 Education 8 Other 9 35. Do you have an undergraduate minor? HEB121 Yes 1 No 2 ==> Skip to Question 37 36. What did you minor in? Mark ? all that apply. Counseling 1 Psychology 2 Social work 3 Nursing 4 Health care administration 5 Biology or other science 6 Business 7 Education 8 Other 9 37. Do you have a graduate degree? Yes 1 No 2 ==> Skip to Question 39 38. In what area or areas? Mark ? all that apply. Counseling 1 Psychology 2 Social work 3 Nursing 4 Medicine 5 Health care administration 6 Biology or other science 7 Business 8 Education 9 Other 10 39. Do you have any of the following credentials or certifications? Yes No a. School Social Work Specialist 1 2 b. National Board of Certified Counselors 1 2 c. National Association of School Psychologists 1 2 40. Are you certified by a state agency or board to provide mental health or social services? If your state does not certify mental health or social services professionals or staff, please mark this box ?. Yes 1 No 2 If you would like to provide any additional comments, please use the space below. Thank you very much for taking the time to participate in this study. Additional Comments Please return this questionnaire to: Don Evers Research Triangle Institute P.O. Box 12194 Research Triangle Park, NC 27709 Mental Health and Social Services District Questionnaires - Final Version — Revised: 10/26/99 8 Mental Health and Social Services District Questionnaires - Final Version — Revised: 10/26/99 Standard Mental Health and Social Services Services Provided at Other Sites Mental Health/Social Services Coordinator