Transition Webpage: Families and Support System
Family and Support System Survey
Please take this survey to see how well you are preparing your youth for health care transition
OK
*
1.
Do you understand your youth’s medical condition?
(Required.)
Yes
No
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2.
Can your youth describe their medical condition?
(Required.)
Yes
No
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3.
Do you have a plan for your youth's following providers:
(Required.)
Primary Care
Specialty Care
Dental Care
Vision Care
I have a plan for my youth's
-- Select an option --
Yes
No
-- Select an option --
Yes
No
N/A
-- Select an option --
Yes
No
-- Select an option --
Yes
No
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4.
Do you feel comfortable that your youth can: properly take medications, schedule an appointment, arrange transportation?
(Required.)
Properly take medications
Schedule an appointment
Arrange transportation
I feel comfortable that my youth can
-- Select an option --
Yes
No
N/A
-- Select an option --
Yes
No
-- Select an option --
Yes
No
*
5.
Is your youth able to care for self?
(Required.)
Yes
No
Not sure
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6.
If your youth is unable to care for self, are you preparing for shared decision making or Guardianship?
(Required.)
Yes
No
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7.
Do you encourage alone time between your youth and his/her doctor?
(Required.)
Yes
No
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8.
Do you encourage your youth to ask questions?
(Required.)
Yes
No
*
9.
Does your youth know about the change in privacy at age 18?
(Required.)
Yes
No
Not sure
*
10.
Do you know how your youth’s medical needs will be paid when they reach adulthood?
(Required.)
Yes
No
Not sure
Current Progress,
0 of 10 answered
