Northern Pines Mental Health Center CTSS Family Survey

1.

Please help our agency make services better by answering some questions about the services your child received OVER THE LAST 3 MONTHS. Your answers are confidential and will not influence the services you or your child receive.

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* 1. Today's Date:

MM/DD/YYYY

Date

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* 2. Does your child currently receive School Based Services, In-Home Services or both?

School Based

In-Home

Both

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* 3. If your child receives In-Home services, please choose which county you live in:

Aitkin

Cass

Crow Wing

Morrison

Todd

Wadena

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* 4. Please select which school your child attends:

Aitkin

Brainerd Learning Center

Brainerd Elementary, including Baxter and Nisswa

Brainerd High School

Crosby/Ironton Elementary School

Crosby/Ironton High School

Discovery Woods Montessori

Forestview Middle School

Little Falls/Randall

Long Prairie/Grey Eagle

McGregor

Mid-State

Eagleview Elementary

Pequot Lakes

Pierz

Pillager

Pine River/Backus

Royalton

Sebeka

Staples/Motley

Swanville

Upsala

Verndale

Wadena/Deer Creek

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* 5. What grade is your child in?

K-6

7-12

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* 6. Collaboration

	Strongly Agree	Agree	Undecided	Disagree	Strongly Disagree	N/A
I believe the goals on my child's treatment plan accurately reflect their strengths and challenges.	I believe the goals on my child's treatment plan accurately reflect their strengths and challenges. Strongly Agree	I believe the goals on my child's treatment plan accurately reflect their strengths and challenges. Agree	I believe the goals on my child's treatment plan accurately reflect their strengths and challenges. Undecided	I believe the goals on my child's treatment plan accurately reflect their strengths and challenges. Disagree	I believe the goals on my child's treatment plan accurately reflect their strengths and challenges. Strongly Disagree	I believe the goals on my child's treatment plan accurately reflect their strengths and challenges. N/A

Comments:

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* 7. Accessibility

	Strongly Agree	Agree	Undecided	Disagree	Strongly Disagree	N/A
Having Northern Pines services in the school is helpful in meeting our needs.	Having Northern Pines services in the school is helpful in meeting our needs. Strongly Agree	Having Northern Pines services in the school is helpful in meeting our needs. Agree	Having Northern Pines services in the school is helpful in meeting our needs. Undecided	Having Northern Pines services in the school is helpful in meeting our needs. Disagree	Having Northern Pines services in the school is helpful in meeting our needs. Strongly Disagree	Having Northern Pines services in the school is helpful in meeting our needs. N/A

Comments:

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* 8. Communication

	Strongly Agree	Agree	Undecided	Disagree	Strongly Disagree	N/A
Staff communicate with me in such a way that I understand my child's diagnosis, goals, treatment and progress.	Staff communicate with me in such a way that I understand my child's diagnosis, goals, treatment and progress. Strongly Agree	Staff communicate with me in such a way that I understand my child's diagnosis, goals, treatment and progress. Agree	Staff communicate with me in such a way that I understand my child's diagnosis, goals, treatment and progress. Undecided	Staff communicate with me in such a way that I understand my child's diagnosis, goals, treatment and progress. Disagree	Staff communicate with me in such a way that I understand my child's diagnosis, goals, treatment and progress. Strongly Disagree	Staff communicate with me in such a way that I understand my child's diagnosis, goals, treatment and progress. N/A
Staff have adequately explained to me the services available to my family and child through the program, as well as other services Northern Pines offers.	Staff have adequately explained to me the services available to my family and child through the program, as well as other services Northern Pines offers. Strongly Agree	Staff have adequately explained to me the services available to my family and child through the program, as well as other services Northern Pines offers. Agree	Staff have adequately explained to me the services available to my family and child through the program, as well as other services Northern Pines offers. Undecided	Staff have adequately explained to me the services available to my family and child through the program, as well as other services Northern Pines offers. Disagree	Staff have adequately explained to me the services available to my family and child through the program, as well as other services Northern Pines offers. Strongly Disagree	Staff have adequately explained to me the services available to my family and child through the program, as well as other services Northern Pines offers. N/A

Comments:

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* 9. Outcomes

	Strongly Agree	Agree	Undecided	Disagree	Strongly Disagree	N/A
I have seen my child make progress as a result of the interventions staff use and the relationships my child has with staff.	I have seen my child make progress as a result of the interventions staff use and the relationships my child has with staff. Strongly Agree	I have seen my child make progress as a result of the interventions staff use and the relationships my child has with staff. Agree	I have seen my child make progress as a result of the interventions staff use and the relationships my child has with staff. Undecided	I have seen my child make progress as a result of the interventions staff use and the relationships my child has with staff. Disagree	I have seen my child make progress as a result of the interventions staff use and the relationships my child has with staff. Strongly Disagree	I have seen my child make progress as a result of the interventions staff use and the relationships my child has with staff. N/A

Comments:

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* 10. Professionalism

	Strongly Agree	Agree	Undecided	Disagree	Strongly Disagree	N/A
Staff treat my family and my child with respect.	Staff treat my family and my child with respect. Strongly Agree	Staff treat my family and my child with respect. Agree	Staff treat my family and my child with respect. Undecided	Staff treat my family and my child with respect. Disagree	Staff treat my family and my child with respect. Strongly Disagree	Staff treat my family and my child with respect. N/A

Comments: