ID# Date / /

62913

Diagnosis, Treatment, and Satisfaction Questionnaire

1. Has your child ever been diagnosed with a mental, emotional, or behavioral disorder?
Yes No (SKIP TO QUESTION 4)

2. If yes, what has he/she been diagnosed with? (select all that apply)

For each selected, is

For each selected, at For each selected,
What has he/she been diagnosed he/she currently
what age was he/she does he/she currently
with? (Select all that apply) taking medication to
diagnosed? have this disorder?
treat this disorder?

Attention-deficit/hyperactivity disorder Yes No Yes No

Oppositional defiant disorder Yes No Yes No

Conduct disorder Yes No Yes No

Depression Yes No Yes No

Mania Yes No Yes No

Bipolar disorder Yes No Yes No

Anxiety disorder (e.g. phobia, panic,

Yes No Yes No
separation, generalized)

Post-traumatic stress disorder Yes No Yes No

Obsessive compulsive disorder Yes No Yes No

Eating disorder Yes No Yes No

Trichotillomania (pulling out his/her hair) Yes No Yes No

Tourette syndrome or other tic disorder Yes No Yes No

Intermittent explosive disorder Yes No Yes No

Elimination disorder Yes No Yes No

Autism spectrum disorder Yes No Yes No

or Asperger's Disorder

Pervasive developmental disorder Yes No Yes No

Sleep disorder Yes No Yes No

Substance use disorder Yes No Yes No

Other Yes No Yes No

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3. Do you belong to a support group for your child's mental, emotional, or behavioral disorder?

Yes No

4. Has your child ever been diagnosed with a seizure disorder or epilepsy?

Yes No (SKIP TO QUESTION 5)

4a. If yes, how many seizures has your child had in the past year?

None 1 2-3 4-10 More than 10

4b. Is your child currently taking any medicine to control the

seizure disorder or epilepsy?

Yes No

5. Has your child ever been diagnosed with:

Intellectual disability or developmental delay Yes No

Learning disability Yes No

Speech or other language problems Yes No

Another developmental delay Yes No

SCHOOL PROGRAMS
6. Has your child ever received any of the following classroom accommodations or special education services?

Extra time for test taking Yes No

Special seating Yes No

Special school-based therapy such as speech therapy,
occupational therapy, or counseling Yes No

Before or after-school tutoring Yes No

Full-time or part-time aide Yes No

Part-time special education classroom/resource
room Yes No

Full-time special education classroom Yes No

Summer school Yes No
Gifted programming Yes No

Other (Specify:______________________) Yes No

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7. Does your child currently have a formal education plan, such as an Individualized Education Program,
also called an IEP, or a 504 plan?

Yes No (SKIP TO QUESTION 8) Not sure (SKIP TO QUESTION 8)

7a. If yes, is it an IEP, a 504 plan, or something else?

IEP 504 Not sure Something else (specify)

SLEEP PROBLEMS

8. On an average night, does your child have difficulty going to sleep? Yes No

9. Does your child snore or have other breathing problems when sleeping? Yes No

10. Is your child a restless sleeper; that is, he/she moves a lot without waking up? Yes No

11. Does your child wake up a lot during the night? Yes No

12. Does your child have a regular bedtime during the week? Yes No

13. Is your child sleepy during the day? Yes No

10 or more
9
8
14. How many hours of sleep does your child get on an average school night?
7
6
5 or less
10 or more
9
8
15. How many hours of sleep does your child get on an average weekend night?
7
6
5 or less

HEALTH INSURANCE

16. Does your child have any kind of health care coverage, including
health insurance, prepaid plans such as HMOs, or government plans Yes No
such as Medicaid?

17. Is your child insured by Medicaid or the Children's Health

Insurance Program, CHIP? (In South Carolina, the program is Yes No
sometimes called Partners for Healthy Children.)
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Never
Sometimes
18. Does your child's health insurance offer benefits or cover services that meet Usually
his/her needs? Always
Not sure
Not applicable

Never
Sometimes
19. Does your child's health insurance allow your child to see the health care
Usually
providers he/she needs?
Always
Not applicable

Never
20. Not including health insurance premiums or costs that are covered by Sometimes
insurance, do you pay any money for your child's health care? Usually
Always

Never
Sometimes
Usually
21. How often are these costs reasonable? Always
No out of pocket costs
Not applicable

ACCESS TO TREATMENT

22. Has there ever been a treatment for a mental, emotional, or behavioral problem you wanted for your
child but could not get?

Yes No (SKIP TO QUESTION 24) Not applicable (SKIP TO QUESTION 24)

22a. If yes, what was the treatment that you could not get?

23. What prevented you from getting this service? (select all that apply)

Cost Distance Unable to secure an appointment

Other (specify)

24. Has your child's mental, emotional, or behavioral problem caused financial problems for the family?

Yes No Not applicable

25. During the past year, has your child received any type of treatment or counseling for a mental, emotional, or
behavioral problem? This may include medication, any kind of behavioral treatment (parent-training, social skills
training, individual or group counseling, family therapy), special diets, dietary supplements, or any other treatment.

Yes (please continue to next page) No (END SURVEY HERE)

 ID# Date / /
NOTE: The remaining questions on this survey refer to treatment for mental, emotional, or behavioral problems in the past year.
26. How many different types of medication has your child taken for mental, emotional, or behavioral problems in the last year?
27. Please list up to four medications your child has taken for mental, emotional, or behavioral problems in the PAST YEAR and complete each row of questions.
Is this Do you think the medicine helped If no longer
Times Days medication your child in these areas? on this
What condition(s) Start usually usually Currently
Medication was this Date taken taking medication,
Name taken per taken during the why did
prescribed for? (Year) day per week With friends medication?
summer? At home At School & classmates he/she stop?
1 or 2 days
0 times
3 days
1 time Yes A lot A lot A lot
4 days Yes
No A little A little A little
2 times 5 days
N/A No No No No
3 or more 6 days
7 days
1 or 2 days
0 times
3 days Yes A lot A lot A lot Yes
1 time 4 days No A little A little A little
2 times 5 days No No No No
N/A
3 or more 6 days
7 days
1 or 2 days
0 times
3 days
Yes A lot A lot A lot Yes
1 time 4 days
No A little A little A little
2 times 5 days
N/A No No No No
3 or more 6 days
7 days
1 or 2 days
0 times
3 days
Yes A lot A lot A lot Yes
1 time 4 days
No A little A little A little
27074
2 times 5 days No
N/A No No No
3 or more 6 days
7 days
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MEDICATIONS: For this section, think about medications your child has taken for mental,
emotional, or behavioral problems.

28. In the past year, has your child had to receive medical care for using too much of his/her medication?

Yes No (SKIP TO QUESTION 29) Not applicable (SKIP TO QUESTION 29)

28a. If yes, did he/she have to go to the emergency room?

Yes No

29. In the past year, has your child stopped taking his/her medication because of a side effect or negative
reaction?

Yes No Not applicable

30. To the best of your knowledge, has your child's medication ever been taken or used by someone else,
including a family member?

Yes No Not applicable

Please continue to next page for additional questions

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31. Please report whether your child has received each type of behavioral therapy in the past year (If none, SKIP TO NEXT PAGE).
Is your
child Has this
Was any of therapy
Average the cost currently
Type of behavioral Provided by (select all that apply) # of Sessions time per helped
intervention covered by receiving your
session insurance? this
therapy? child?

Hours
Mental Health Provider in school It was free
Other school professional Yes
All Yes
Individual counseling Mental Health Provider outside school
Minutes
Other physician/pediatrician Some
No No
Other None
Hours
Mental Health Provider in school
It was free
Other school professional
Family group therapy All Yes Yes
Mental Health Provider outside school
(sessions you and your Minutes
child attend together) Other physician/pediatrician Some No No
Other None
Hours
Mental Health Provider in school It was free
Other school professional Yes Yes
All
Group counseling Mental Health Provider outside school
Minutes
Other physician/pediatrician Some No No
Other None

Hours
Mental Health Provider in school It was free
Other school professional All Yes Yes
Social skills training Mental Health Provider outside school
Minutes Some
Other physician/pediatrician No No
Other None

Hours It was free

Mental Health Provider in school
Other school professional All Yes Yes
Cognitive behavioral
Mental Health Provider outside school
therapy Minutes Some
Other physician/pediatrician No No
Other None

Hours It was free

Mental Health Provider in school
Comprehensive Other school professional All Yes Yes
behavioral Mental Health Provider outside school
intervention for tics Minutes Some
Other physician/pediatrician No No
Other None
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32. In the past year, have you received parent training as related to your child's mental, emotional, or
behavioral problem? (parent training includes sessions that you attend without your child and you learn
strategies to try at home to help change your child's behavior)
Yes No (SKIP TO QUESTION 33)

32a. If yes, provided by (select all that apply):

Mental Health Provider in school
Other school professional
Mental Health Provider outside school
Other physician/pediatrician
Other
32b. How much parent training did you receive in the past year?
Number of sessions Hours per session

32c. Was any of the cost covered by insurance?

Yes No Training was free
32d. Are you currently receiving this training?
Yes No
32e. Has this treatment helped your child?
Yes No

33. In the past year, have you made dietary changes for his/her mental, emotional, or behavioral
problem?
Yes No (SKIP TO QUESTION 34)

32a. If yes, who suggested the dietary change? (select all that apply):

Mental Health Provider in school

Other school professional
Mental Health Provider outside school
Other physician/pediatrician
Other

32b. Type of diet

33c. Has this diet change helped your child?

Yes No
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34. In the past year, has your child taken dietary supplements (for example, vitamins and/or herbs)
for a mental, emotional, or behavioral problem?
Yes No (SKIP TO QUESTION 35)

34a. If yes, how many?

34b. Please list the dietary supplements your child has taken (for example, fish oil or
Omega fatty acids, zinc, chamomile, kava hops, lemon balm, valerian root, passion
flower, melatonin, ginko biloba, pycnogenol, nystatin, ketonazole, piracetam,
dimethylaminoethanol, linoleic, linolenic acids, megavitamins):

Supplement 1:

Supplement 2:

Supplement 3:

Supplement 4:

34c. Have these supplements helped your child?

Yes No

35. In the past year, has your child received other services or therapies for a mental, emotional, or
behavioral problem, including chiropractic care, acupuncture, light therapy, sensory integration, or
biofeedback?
Yes No (SKIP TO QUESTION 36)

35a. If yes, list:

35b. If yes, provided by (select all that apply):

Mental Health Provider in school
Other school professional
Mental Health Provider outside school
Other physician/pediatrician
Other

35c. How much did your child receive in the past year?
Number of times Hours per session
32c. Was any of the cost covered by insurance?
Yes No It was free
32d. Are you currently receiving this treatment?
Yes No
32e. Has this treatment helped your child?
Yes No
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36. Has your child ever received any of the following treatment types for a mental, emotional, or
behavioral problem? (select all that apply)

Inpatient psychiatric hospital stay

Day treatment program
Emergency room visit
None of these

TREATMENT COSTS: For this section, think about treatments your child has received for mental,
emotional, or behavioral problems.

37. How many hours per month do you or other family members spend taking your child to the
doctor or to receive treatments, including counseling?

Hours

38. During the past year, how much has your family paid out-of-pocket for your child's behavioral or
mental health-related needs?

Nothing, $0

$1-$249

$250-$500

More than $500

39. Did you ever stop or not start a treatment, or decide not to buy a medication for your child's condition
because it was too expensive?

Yes No Not applicable