Form Instrument

Appendix D - Social Network Analysis Survey

OMB No. 0930-xxxx

Expiration Date:

Public Burden Statement: 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.  The OMB control number for this project is 0930-xxxx.  Public reporting burden for this collection of information is estimated to average xx hours per client per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

Building Transition Systems:

Interorganizational Linkages,

Opportunities & Youth Outcomes

A Study of the Child to Adult Transition Network for Clark County,

Washington

PART I: Agency Characteristics

Agency and Program Name: _________________________________________

Respondent’s Name: _________________________________________

Interviewer’s Name: _________________________________________

Date of Interview: _________________________________________

Time Started: _________________________________________

Time Finished: _________________________________________

A survey conducted by Center for Mental Health Services Research, University of Massachusetts Medical School, in collaboration with Portland State University and the support of the Clark County Regional Support Network.

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Respondents

SECTION 1: GENERAL INFORMATION

1.01 What is the name of your program/agency? __________________________________

1.02 What types of services does your program/agency offer? [show card] (Circle one or more of the following services areas).

1…… Mental Health Service

2…… Vocational Rehabilitation Service

3…… Education or Special Education Service

4…… Substance Abuse Service

5…… Developmental Disability Service

6…… Housing Service

7…… Independent Living Service

8…… Delinquency Rehabilitation Service

9…… Child Welfare Services

10…. Child Protection Service

11…. Public Safety Service

12…. Medical Health Service

13…. Recreation Service

14…. Other ______________________________________________________

1.03 What are your specific job responsibilities? [show card] (Circle all that apply)

1…… Administration

2…… Training

3…… Fiscal Management

4…… Accounting

5…… Clinical Care or Supervision

6…… Case Management

7…… Other______________________________________________________

The following questions are aimed at understanding the services offered by your program. By this, we mean those services offered by _______________________________________________.

1.04 How long has your program/agency been providing services? _________ years

1.05 How many clients received services in your program/agency in FY 2003? _________

[Please note, this should be an unduplicated count – number of distinct individuals]

6. Please estimate the age composition of your program’s (agency’s) clients based on the unduplicated count above. [show card] About what proportion are:

a. 13 and under? ________%

b. 14-17 year olds? ________%

c. 18-21 year olds? ________%

d. 22-25 year olds? ________%

e. Over 25? ________%

100% TOTAL

1.07 Please estimate the gender composition of your program’s (agency’s) clients based on the unduplicated count above. What proportion are:

a. Female? ________%

b. Male? ________%

100% TOTAL

1.08 Please estimate the ethnic and racial composition of clients in your program/agency, based on the unduplicated count above. [show card]

1) What proportion are: Hispanic or Latino?

2) What proportion are:

a. White? ________%

b. Asian? ________%

c. Native Hawaiian or other Pacific Islander? ________%

d. Black or African American? ________%

e. American Indian or Alaska Native? ________%

f. Other? ________%

100% TOTAL

1.09. Within those aged 14-25, what proportion have serious emotional disturbance or serious mental illness? ________%

Building Transition Systems:

Interorganizational Linkages,

Opportunities & Youth Outcomes

A Study of the Child to Adult Transition Network for Clark County,

Washington

PART II:

Respondent’s Organization: ______________________________________

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# Respondents

2.1 How often do staff in your program/agency meet with staff in this other program/agency for client planning purposes? Respond to each program on the list by circling a number from 1 to 5, where 1 is equal to “Not At All” and 5 is equal to “Very Often” indicating the degree of interrelationship.

	Battle Ground School Department								54	Prevention Intervention Specialist	1	2	3	4	5	9
1	Prairie High School	1	2	3	4	5	9		55	Legacy High School	1	2	3	4	5	9
2	Special Services	1	2	3	4	5	9		56	Family Solutions	1	2	3	4	5	9
3	Summit View High School	1	2	3	4	5	9		57	4H Juvenile Justice Comm. Svc. Club	1	2	3	4	5	9
4	Camas School Dept. /Special Svcs.	1	2	3	4	5	9		58	Goldman & Associates	1	2	3	4	5	9
5	Cascade AIDS Project	1	2	3	4	5	9		59	Hockinson School District/Special Svcs.	1	2	3	4	5	9
6	Catholic Community Services	1	2	3	4	5	9		60	Janus Youth Programs	1	2	3	4	5	9
7	Children’s Center	1	2	3	4	5	9		61	MY House	1	2	3	4	5	9
8	Children’s Home Society	1	2	3	4	5	9		62	Oak Bridge	1	2	3	4	5	9
9	Council for the Homeless Clark Coll.	1	2	3	4	5	9		63	Oak Grove	1	2	3	4	5	9
10	Adult Basic Education	1	2	3	4	5	9		64	Juvenile Rehabilitation	1	2	3	4	5	9
11	Career Center/ Financial Aid	1	2	3	4	5	9		65	Kaiser Permanente Cascade Park	1	2	3	4	5	9
12	GED Program	1	2	3	4	5	9		66	Keys to Advancement	1	2	3	4	5	9
13	Clark Co Dept of Community Svcs	1	2	3	4	5	9		67	LaCenter School District/Special Svcs.	1	2	3	4	5	9
14	Clark County Youth Commission	1	2	3	4	5	9		68	Mental Health NW	1	2	3	4	5	9
15	Developmental Disabilities	1	2	3	4	5	9		69	Intensive Case Management	1	2	3	4	5	9
16	Drug and Alcohol	1	2	3	4	5	9		70	PACT	1	2	3	4	5	9
	Clark County Health Department								71	Outpatient Treatment	1	2	3	4	5	9
17	Teen Clinic	1	2	3	4	5	9		72	Mission Possible	1	2	3	4	5	9
19	Clark County Juvenile Services	1	2	3	4	5	9		73	NAMI	1	2	3	4	5	9
20	Connections	1	2	3	4	5	9		74	Nelson & Associates	1	2	3	4	5	9
20.5	GED/GAP	1	2	3	4	5	9		75	North County Family Resources Ctr.	1	2	3	4	5	9
21	SSODA	1	2	3	4	5	9		76	NW Counseling Associates	1	2	3	4	5	9
22	Clark County Parks & Recreation	1	2	3	4	5	9		77	NW Deaf Addiction Ctr./Pacific Crest	1	2	3	4	5	9
23	Columbia River Mental Health Svcs	1	2	3	4	5	9		78	Ombudsman	1	2	3	4	5	9
24	Center for Dual Diagnosis	1	2	3	4	5	9		79	Parent Partner Program	1	2	3	4	5	9
25	Child & Family Services	1	2	3	4	5	9		80	Planned Parenthood-Vancouver	1	2	3	4	5	9
26	Clearview	1	2	3	4	5	9		81	Recovery NW	1	2	3	4	5	9
27	Crisis Services	1	2	3	4	5	9		82	Regional Support Network (RSN)	1	2	3	4	5	9
28	Elahan Place	1	2	3	4	5	9		83	Care Management Team	1	2	3	4	5	9
28.5	4 Results Mentoring Services	1	2	3	4	5	9		84	Ridgefield School District/Special Svcs.	1	2	3	4	5	9
29	Hospital Alternative Services (HAS)	1	2	3	4	5	9		85	The Right Choice	1	2	3	4	5	9
30	Intensive Case Management	1	2	3	4	5	9		86	SEH America	1	2	3	4	5	9
31	Victim Assistance Program	1	2	3	4	5	9		87	Service Alternatives	1	2	3	4	5	9
32	Community Drug & Alcohol Ctr (CDAC)	1	2	3	4	5	9			Southwest WA Medical Center
33	Community Empowerment Program	1	2	3	4	5	9		88	Station 2	1	2	3	4	5	9
34	Community Pregnancy Program	1	2	3	4	5	9		89	ADAPT	1	2	3	4	5	9
35	Community Resource Mentors	1	2	3	4	5	9		89.5	Emergency Dept. Crisis Team	1	2	3	4	5	9
36	Consumer Voices are Born	1	2	3	4	5	9			South West Health District
37	Daybreak (Inpatient Treatment)	1	2	3	4	5	9		90	Family Planning Birth Control	1	2	3	4	5	9
38	Dept. of Child & Family Svcs. (DCFS)	1	2	3	4	5	9		91	Steps to the Future	1	2	3	4	5	9
39	Family Reconciliation Services	1	2	3	4	5	9			Vancouver School District	1	2	3	4	5	9
40	Child Protection	1	2	3	4	5	9		92	Fir Grove/Vista	1	2	3	4	5	9
41	Child Welfare Services	1	2	3	4	5	9		93	Lewis & Clark High School	1	2	3	4	5	9
42	Dept. of Vocational Rehabilitation	1	2	3	4	5	9		94	Special Services	1	2	3	4	5	9
43	Division of Developmental Disabilities (DDD)	1	2	3	4	5	9		95	Hudson’s Bay High School	1	2	3	4	5	9
44	Employers Overload	1	2	3	4	5	9		96	I have a Dream Program	1	2	3	4	5	9
45	Encore Group NW	1	2	3	4	5	9		97	Magnet Career Mentoring	1	2	3	4	5	9
	Educational Services District (ESD)112								98	Teen Parent Program	1	2	3	4	5	9
46	Clark County Skill Center	1	2	3	4	5	9		99	WSU Career Center/Financial Aid	1	2	3	4	5	9
47	Direct Services Division	1	2	3	4	5	9		100	Washougal School District/Special Svcs	1	2	3	4	5	9
48	Truancy Program	1	2	3	4	5	9		101	Western Psychology & Counseling Svcs	1	2	3	4	5	9
49	Youth Svcs/Youth Workforces (WIA)	1	2	3	4	5	9		102	Western State Psychiatric Hospital	1	2	3	4	5	9
50	Youth Svcs/Credit Recovery Program	1	2	3	4	5	9		103	WorkSource/Private Industry Council	1	2	3	4	5	9
51	Evergreen Inn	1	2	3	4	5	9		104	YLEAD	1	2	3	4	5	9
	Evergreen School Department								105	YMCA	1	2	3	4	5	9
52	Special Services	1	2	3	4	5	9		106	YWCA/Independent Living Skills	1	2	3	4	5	9
53	Evergreen High School	1	2	3	4	5	9		107	YWCA/CASA	1	2	3	4	5	9

2.2 How often do staff or administrators in your agency/program and these agency/programs meet together to discuss issues of mutual interest? Respond to each program on the list by circling a number from 1 to 5, where 1 is equal to “Not At All” and 5 is equal to “Very Often” indicating the degree of interrelationship.

	Battle Ground School Department								54	Prevention Intervention Specialist	1	2	3	4	5	9
1	Prairie High School	1	2	3	4	5	9		55	Legacy High School	1	2	3	4	5	9
2	Special Services	1	2	3	4	5	9		56	Family Solutions	1	2	3	4	5	9
3	Summit View High School	1	2	3	4	5	9		57	4H Juvenile Justice Comm. Svc. Club	1	2	3	4	5	9
4	Camas School Dept. /Special Svcs.	1	2	3	4	5	9		58	Goldman & Associates	1	2	3	4	5	9
5	Cascade AIDS Project	1	2	3	4	5	9		59	Hockinson School District/Special Svcs.	1	2	3	4	5	9
6	Catholic Community Services	1	2	3	4	5	9		60	Janus Youth Programs	1	2	3	4	5	9
7	Children’s Center	1	2	3	4	5	9		61	MY House	1	2	3	4	5	9
8	Children’s Home Society	1	2	3	4	5	9		62	Oak Bridge	1	2	3	4	5	9
9	Council for the Homeless Clark Coll.	1	2	3	4	5	9		63	Oak Grove	1	2	3	4	5	9
10	Adult Basic Education	1	2	3	4	5	9		64	Juvenile Rehabilitation	1	2	3	4	5	9
11	Career Center/ Financial Aid	1	2	3	4	5	9		65	Kaiser Permanente Cascade Park	1	2	3	4	5	9
12	GED Program	1	2	3	4	5	9		66	Keys to Advancement	1	2	3	4	5	9
13	Clark Co Dept of Community Svcs	1	2	3	4	5	9		67	LaCenter School District/Special Svcs.	1	2	3	4	5	9
14	Clark County Youth Commission	1	2	3	4	5	9		68	Mental Health NW	1	2	3	4	5	9
15	Developmental Disabilities	1	2	3	4	5	9		69	Intensive Case Management	1	2	3	4	5	9
16	Drug and Alcohol	1	2	3	4	5	9		70	PACT	1	2	3	4	5	9
	Clark County Health Department								71	Outpatient Treatment	1	2	3	4	5	9
17	Teen Clinic	1	2	3	4	5	9		72	Mission Possible	1	2	3	4	5	9
19	Clark County Juvenile Services	1	2	3	4	5	9		73	NAMI	1	2	3	4	5	9
20	Connections	1	2	3	4	5	9		74	Nelson & Associates	1	2	3	4	5	9
20.5	GED/GAP	1	2	3	4	5	9		75	North County Family Resources Ctr.	1	2	3	4	5	9
21	SSODA	1	2	3	4	5	9		76	NW Counseling Associates	1	2	3	4	5	9
22	Clark County Parks & Recreation	1	2	3	4	5	9		77	NW Deaf Addiction Ctr./Pacific Crest	1	2	3	4	5	9
23	Columbia River Mental Health Svcs	1	2	3	4	5	9		78	Ombudsman	1	2	3	4	5	9
24	Center for Dual Diagnosis	1	2	3	4	5	9		79	Parent Partner Program	1	2	3	4	5	9
25	Child & Family Services	1	2	3	4	5	9		80	Planned Parenthood-Vancouver	1	2	3	4	5	9
26	Clearview	1	2	3	4	5	9		81	Recovery NW	1	2	3	4	5	9
27	Crisis Services	1	2	3	4	5	9		82	Regional Support Network (RSN)	1	2	3	4	5	9
28	Elahan Place	1	2	3	4	5	9		83	Care Management Team	1	2	3	4	5	9
28.5	4 Results Mentoring Services	1	2	3	4	5	9		84	Ridgefield School District/Special Svcs.	1	2	3	4	5	9
29	Hospital Alternative Services (HAS)	1	2	3	4	5	9		85	The Right Choice	1	2	3	4	5	9
30	Intensive Case Management	1	2	3	4	5	9		86	SEH America	1	2	3	4	5	9
31	Victim Assistance Program	1	2	3	4	5	9		87	Service Alternatives	1	2	3	4	5	9
32	Community Drug & Alcohol Ctr (CDAC)	1	2	3	4	5	9			Southwest WA Medical Center	1	2	3	4	5	9
33	Community Empowerment Program	1	2	3	4	5	9		88	Station 2	1	2	3	4	5	9
34	Community Pregnancy Program	1	2	3	4	5	9		89	ADAPT	1	2	3	4	5	9
35	Community Resource Mentors	1	2	3	4	5	9		89.5	Emergency Dept. Crisis Team	1	2	3	4	5	9
36	Consumer Voices are Born	1	2	3	4	5	9			South West Health District
37	Daybreak (Inpatient Treatment)	1	2	3	4	5	9		90	Family Planning Birth Control	1	2	3	4	5	9
38	Dept. of Child & Family Svcs. (DCFS)	1	2	3	4	5	9		91	Steps to the Future	1	2	3	4	5	9
39	Family Reconciliation Services	1	2	3	4	5	9			Vancouver School District
40	Child Protection	1	2	3	4	5	9		92	Fir Grove/Vista	1	2	3	4	5	9
41	Child Welfare Services	1	2	3	4	5	9		93	Lewis & Clark High School	1	2	3	4	5	9
42	Dept. of Vocational Rehabilitation	1	2	3	4	5	9		94	Special Services	1	2	3	4	5	9
43	Division of Developmental Disabilities (DDD)	1	2	3	4	5	9		95	Hudson’s Bay High School	1	2	3	4	5	9
44	Employers Overload	1	2	3	4	5	9		96	I have a Dream Program	1	2	3	4	5	9
45	Encore Group NW	1	2	3	4	5	9		97	Magnet Career Mentoring	1	2	3	4	5	9
	Educational Services District (ESD)112								98	Teen Parent Program	1	2	3	4	5	9
46	Clark County Skill Center	1	2	3	4	5	9		99	WSU Career Center/Financial Aid	1	2	3	4	5	9
47	Direct Services Division	1	2	3	4	5	9		100	Washougal School District/Special Svcs	1	2	3	4	5	9
48	Truancy Program	1	2	3	4	5	9		101	Western Psychology & Counseling Svcs	1	2	3	4	5	9
49	Youth Svcs/Youth Workforces (WIA)	1	2	3	4	5	9		102	Western State Psychiatric Hospital	1	2	3	4	5	9
50	Youth Svcs/Credit Recovery Program	1	2	3	4	5	9		103	WorkSource/Private Industry Council	1	2	3	4	5	9
51	Evergreen Inn	1	2	3	4	5	9		104	YLEAD	1	2	3	4	5	9
	Evergreen School Department								105	YMCA	1	2	3	4	5	9
52	Special Services	1	2	3	4	5	9		106	YWCA/Independent Living Skills	1	2	3	4	5	9
53	Evergreen High School	1	2	3	4	5	9		107	YWCA/CASA	1	2	3	4	5	9

2.3 How often does your agency/program refer clients to this other agency/program?

R espond to each program on the list by circling a number from 1 to 5, where 1 is equal to “Not At All” and 5 is equal to “Very Often” indicating the degree of interrelationship.

	Battle Ground School Department	1	2	3	4	5	9		54	Prevention Intervention Specialist	1	2	3	4	5	9
1	Prairie High School	1	2	3	4	5	9		55	Legacy High School	1	2	3	4	5	9
2	Special Services	1	2	3	4	5	9		56	Family Solutions	1	2	3	4	5	9
3	Summit View High School	1	2	3	4	5	9		57	4H Juvenile Justice Comm. Svc. Club	1	2	3	4	5	9
4	Camas School Dept. /Special Svcs.	1	2	3	4	5	9		58	Goldman & Associates	1	2	3	4	5	9
5	Cascade AIDS Project	1	2	3	4	5	9		59	Hockinson School District/Special Svcs.	1	2	3	4	5	9
6	Catholic Community Services	1	2	3	4	5	9		60	Janus Youth Programs	1	2	3	4	5	9
7	Children’s Center	1	2	3	4	5	9		61	MY House	1	2	3	4	5	9
8	Children’s Home Society	1	2	3	4	5	9		62	Oak Bridge	1	2	3	4	5	9
9	Council for the Homeless Clark Coll.	1	2	3	4	5	9		63	Oak Grove	1	2	3	4	5	9
10	Adult Basic Education	1	2	3	4	5	9		64	Juvenile Rehabilitation	1	2	3	4	5	9
11	Career Center/ Financial Aid	1	2	3	4	5	9		65	Kaiser Permanente Cascade Park	1	2	3	4	5	9
12	GED Program	1	2	3	4	5	9		66	Keys to Advancement	1	2	3	4	5	9
13	Clark Co Dept of Community Svcs	1	2	3	4	5	9		67	LaCenter School District/Special Svcs.	1	2	3	4	5	9
14	Clark County Youth Commission	1	2	3	4	5	9		68	Mental Health NW	1	2	3	4	5	9
15	Developmental Disabilities	1	2	3	4	5	9		69	Intensive Case Management	1	2	3	4	5	9
16	Drug and Alcohol	1	2	3	4	5	9		70	PACT	1	2	3	4	5	9
	Clark County Health Department	1	2	3	4	5	9		71	Outpatient Treatment	1	2	3	4	5	9
17	Teen Clinic	1	2	3	4	5	9		72	Mission Possible	1	2	3	4	5	9
19	Clark County Juvenile Services	1	2	3	4	5	9		73	NAMI	1	2	3	4	5	9
20	Connections	1	2	3	4	5	9		74	Nelson & Associates	1	2	3	4	5	9
20.5	GED/GAP	1	2	3	4	5	9		75	North County Family Resources Ctr.	1	2	3	4	5	9
21	SSODA	1	2	3	4	5	9		76	NW Counseling Associates	1	2	3	4	5	9
22	Clark County Parks & Recreation	1	2	3	4	5	9		77	NW Deaf Addiction Ctr./Pacific Crest	1	2	3	4	5	9
23	Columbia River Mental Health Svcs	1	2	3	4	5	9		78	Ombudsman	1	2	3	4	5	9
24	Center for Dual Diagnosis	1	2	3	4	5	9		79	Parent Partner Program	1	2	3	4	5	9
25	Child & Family Services	1	2	3	4	5	9		80	Planned Parenthood-Vancouver	1	2	3	4	5	9
26	Clearview	1	2	3	4	5	9		81	Recovery NW	1	2	3	4	5	9
27	Crisis Services	1	2	3	4	5	9		82	Regional Support Network (RSN)	1	2	3	4	5	9
28	Elahan Place	1	2	3	4	5	9		83	Care Management Team	1	2	3	4	5	9
28.5	4 Results Mentoring Services	1	2	3	4	5	9		84	Ridgefield School District/Special Svcs.	1	2	3	4	5	9
29	Hospital Alternative Services (HAS)	1	2	3	4	5	9		85	The Right Choice	1	2	3	4	5	9
30	Intensive Case Management	1	2	3	4	5	9		86	SEH America	1	2	3	4	5	9
31	Victim Assistance Program	1	2	3	4	5	9		87	Service Alternatives	1	2	3	4	5	9
32	Community Drug & Alcohol Ctr (CDAC)	1	2	3	4	5	9			Southwest WA Medical Center	1	2	3	4	5	9
33	Community Empowerment Program	1	2	3	4	5	9		88	Station 2	1	2	3	4	5	9
34	Community Pregnancy Program	1	2	3	4	5	9		89	ADAPT	1	2	3	4	5	9
35	Community Resource Mentors	1	2	3	4	5	9		89.5	Emergency Dept. Crisis Team	1	2	3	4	5	9
36	Consumer Voices are Born	1	2	3	4	5	9			South West Health District	1	2	3	4	5	9
37	Daybreak (Inpatient Treatment)	1	2	3	4	5	9		90	Family Planning Birth Control	1	2	3	4	5	9
38	Dept. of Child & Family Svcs. (DCFS)	1	2	3	4	5	9		91	Steps to the Future	1	2	3	4	5	9
39	Family Reconciliation Services	1	2	3	4	5	9			Vancouver School District	1	2	3	4	5	9
40	Child Protection	1	2	3	4	5	9		92	Fir Grove/Vista	1	2	3	4	5	9
41	Child Welfare Services	1	2	3	4	5	9		93	Lewis & Clark High School	1	2	3	4	5	9
42	Dept. of Vocational Rehabilitation	1	2	3	4	5	9		94	Special Services	1	2	3	4	5	9
43	Division of Developmental Disabilities (DDD)	1	2	3	4	5	9		95	Hudson’s Bay High School	1	2	3	4	5	9
44	Employers Overload	1	2	3	4	5	9		96	I have a Dream Program	1	2	3	4	5	9
45	Encore Group NW	1	2	3	4	5	9		97	Magnet Career Mentoring	1	2	3	4	5	9
	Educational Services District (ESD)112	1	2	3	4	5	9		98	Teen Parent Program	1	2	3	4	5	9
46	Clark County Skill Center	1	2	3	4	5	9		99	WSU Career Center/Financial Aid	1	2	3	4	5	9
47	Direct Services Division	1	2	3	4	5	9		100	Washougal School District/Special Svcs	1	2	3	4	5	9
48	Truancy Program	1	2	3	4	5	9		101	Western Psychology & Counseling Svcs	1	2	3	4	5	9
49	Youth Svcs/Youth Workforces (WIA)	1	2	3	4	5	9		102	Western State Psychiatric Hospital	1	2	3	4	5	9
50	Youth Svcs/Credit Recovery Program	1	2	3	4	5	9		103	WorkSource/Private Industry Council	1	2	3	4	5	9
51	Evergreen Inn	1	2	3	4	5	9		104	YLEAD	1	2	3	4	5	9
	Evergreen School Department	1	2	3	4	5	9		105	YMCA	1	2	3	4	5	9
52	Special Services	1	2	3	4	5	9		106	YWCA/Independent Living Skills	1	2	3	4	5	9
53	Evergreen High School	1	2	3	4	5	9		107	YWCA/CASA	1	2	3	4	5	9

2.4 How often does your agency/program receive client referrals from this other agency/program?

Respond to each program on the list by circling a number from 1 to 5, where 1 is equal to “Not At All” and 5 is equal to “Very Often” indicating the degree of interrelationship.

	Battle Ground School Department	1	2	3	4	5	9		54	Prevention Intervention Specialist	1	2	3	4	5	9
1	Prairie High School	1	2	3	4	5	9		55	Legacy High School	1	2	3	4	5	9
2	Special Services	1	2	3	4	5	9		56	Family Solutions	1	2	3	4	5	9
3	Summit View High School	1	2	3	4	5	9		57	4H Juvenile Justice Comm. Svc. Club	1	2	3	4	5	9
4	Camas School Dept. /Special Svcs.	1	2	3	4	5	9		58	Goldman & Associates	1	2	3	4	5	9
5	Cascade AIDS Project	1	2	3	4	5	9		59	Hockinson School District/Special Svcs.	1	2	3	4	5	9
6	Catholic Community Services	1	2	3	4	5	9		60	Janus Youth Programs	1	2	3	4	5	9
7	Children’s Center	1	2	3	4	5	9		61	MY House	1	2	3	4	5	9
8	Children’s Home Society	1	2	3	4	5	9		62	Oak Bridge	1	2	3	4	5	9
9	Council for the Homeless Clark Coll.	1	2	3	4	5	9		63	Oak Grove	1	2	3	4	5	9
10	Adult Basic Education	1	2	3	4	5	9		64	Juvenile Rehabilitation	1	2	3	4	5	9
11	Career Center/ Financial Aid	1	2	3	4	5	9		65	Kaiser Permanente Cascade Park	1	2	3	4	5	9
12	GED Program	1	2	3	4	5	9		66	Keys to Advancement	1	2	3	4	5	9
13	Clark Co Dept of Community Svcs	1	2	3	4	5	9		67	LaCenter School District/Special Svcs.	1	2	3	4	5	9
14	Clark County Youth Commission	1	2	3	4	5	9		68	Mental Health NW	1	2	3	4	5	9
15	Developmental Disabilities	1	2	3	4	5	9		69	Intensive Case Management	1	2	3	4	5	9
16	Drug and Alcohol	1	2	3	4	5	9		70	PACT	1	2	3	4	5	9
	Clark County Health Department	1	2	3	4	5	9		71	Outpatient Treatment	1	2	3	4	5	9
17	Teen Clinic	1	2	3	4	5	9		72	Mission Possible	1	2	3	4	5	9
19	Clark County Juvenile Services	1	2	3	4	5	9		73	NAMI	1	2	3	4	5	9
20	Connections	1	2	3	4	5	9		74	Nelson & Associates	1	2	3	4	5	9
20.5	GED/GAP	1	2	3	4	5	9		75	North County Family Resources Ctr.	1	2	3	4	5	9
21	SSODA	1	2	3	4	5	9		76	NW Counseling Associates	1	2	3	4	5	9
22	Clark County Parks & Recreation	1	2	3	4	5	9		77	NW Deaf Addiction Ctr./Pacific Crest	1	2	3	4	5	9
23	Columbia River Mental Health Svcs	1	2	3	4	5	9		78	Ombudsman	1	2	3	4	5	9
24	Center for Dual Diagnosis	1	2	3	4	5	9		79	Parent Partner Program	1	2	3	4	5	9
25	Child & Family Services	1	2	3	4	5	9		80	Planned Parenthood-Vancouver	1	2	3	4	5	9
26	Clearview	1	2	3	4	5	9		81	Recovery NW	1	2	3	4	5	9
27	Crisis Services	1	2	3	4	5	9		82	Regional Support Network (RSN)	1	2	3	4	5	9
28	Elahan Place	1	2	3	4	5	9		83	Care Management Team	1	2	3	4	5	9
28.5	4 Results Mentoring Services	1	2	3	4	5	9		84	Ridgefield School District/Special Svcs.	1	2	3	4	5	9
29	Hospital Alternative Services (HAS)	1	2	3	4	5	9		85	The Right Choice	1	2	3	4	5	9
30	Intensive Case Management	1	2	3	4	5	9		86	SEH America	1	2	3	4	5	9
31	Victim Assistance Program	1	2	3	4	5	9		87	Service Alternatives	1	2	3	4	5	9
32	Community Drug & Alcohol Ctr (CDAC)	1	2	3	4	5	9			Southwest WA Medical Center	1	2	3	4	5	9
33	Community Empowerment Program	1	2	3	4	5	9		88	Station 2	1	2	3	4	5	9
34	Community Pregnancy Program	1	2	3	4	5	9		89	ADAPT	1	2	3	4	5	9
35	Community Resource Mentors	1	2	3	4	5	9		89.5	Emergency Dept. Crisis Team	1	2	3	4	5	9
36	Consumer Voices are Born	1	2	3	4	5	9			South West Health District	1	2	3	4	5	9
37	Daybreak (Inpatient Treatment)	1	2	3	4	5	9		90	Family Planning Birth Control	1	2	3	4	5	9
38	Dept. of Child & Family Svcs. (DCFS)	1	2	3	4	5	9		91	Steps to the Future	1	2	3	4	5	9
39	Family Reconciliation Services	1	2	3	4	5	9			Vancouver School District	1	2	3	4	5	9
40	Child Protection	1	2	3	4	5	9		92	Fir Grove/Vista	1	2	3	4	5	9
41	Child Welfare Services	1	2	3	4	5	9		93	Lewis & Clark High School	1	2	3	4	5	9
42	Dept. of Vocational Rehabilitation	1	2	3	4	5	9		94	Special Services	1	2	3	4	5	9
43	Division of Developmental Disabilities (DDD)	1	2	3	4	5	9		95	Hudson’s Bay High School	1	2	3	4	5	9
44	Employers Overload	1	2	3	4	5	9		96	I have a Dream Program	1	2	3	4	5	9
45	Encore Group NW	1	2	3	4	5	9		97	Magnet Career Mentoring	1	2	3	4	5	9
	Educational Services District (ESD)112	1	2	3	4	5	9		98	Teen Parent Program	1	2	3	4	5	9
46	Clark County Skill Center	1	2	3	4	5	9		99	WSU Career Center/Financial Aid	1	2	3	4	5	9
47	Direct Services Division	1	2	3	4	5	9		100	Washougal School District/Special Svcs	1	2	3	4	5	9
48	Truancy Program	1	2	3	4	5	9		101	Western Psychology & Counseling Svcs	1	2	3	4	5	9
49	Youth Svcs/Youth Workforces (WIA)	1	2	3	4	5	9		102	Western State Psychiatric Hospital	1	2	3	4	5	9
50	Youth Svcs/Credit Recovery Program	1	2	3	4	5	9		103	WorkSource/Private Industry Council	1	2	3	4	5	9
51	Evergreen Inn	1	2	3	4	5	9		104	YLEAD	1	2	3	4	5	9
	Evergreen School Department	1	2	3	4	5	9		105	YMCA	1	2	3	4	5	9
52	Special Services	1	2	3	4	5	9		106	YWCA/Independent Living Skills	1	2	3	4	5	9
53	Evergreen High School	1	2	3	4	5	9		107	YWCA/CASA	1	2	3	4	5	9

Section 2B: Services provided directly by your Agency to 14-25 year olds. Wave 1 - ID __ __ __

Do you provide this service to:

Do you provide this service to:

Do you provide this service at all? 1

14-17 year olds? 2

18-21 year olds? 3

22-25 year olds? 4

26 years or older? 5

Do you provide this service at all? 1

14-17 year olds? 2

18-21 year olds? 3

22-25 year olds? 4

26 years or older? 5

Mental Health Services

Schools and Colleges

Outpatient/Community-Based Treatment

High School

Office-Based Outpatient Treatment

Vocational School

Home-Based Outpatient Treatment

Community College

Wraparound Services

Vocational Rehabilitation/Training

Medication Management

Tutoring

Emergency Services

Transition Planning

Drop-in Center

GED Preparation

Respite Care

Special Education Advocacy

Hospital Based Services

Vocational Services

Partial Hospitalization

Vocational Counseling

Inpatient Hospitalization

Vocational Training

State Psychiatric Hospital

Sheltered Employment

Private Psychiatric Hospital

Substance Abuse Services

Other Related Mental Health Services

Detox Treatment/Residence

Case Management

Inpatient Substance Abuse Treatment

Consumer Operated Service Program

Spec MH/Substance Abuse Services

Supported Employment

Health Services

Psychosocial Rehabilitation

Sexual Health/Family Planning

Clubhouse

Public Health Clinic

Assertive Community Treatment

Housing/Homeless

Mentoring Program

Homeless Shelter

Multisystemic Therapy

Mobile Outreach

Therapeutic Foster Care

Criminal Justice/Juvenile Justice

Residential Services

Corrections Facility/Jail

Residential Treatment

Juvenile Detention Facility

Residential Respite

Legal Aid

Supervised Housing

Legal Advocate

Group Home

Probation

Supported Housing

Other

Social Services

Recreation Programs

Child Protective Services

Advocacy

Foster Care

Case Management

Income Support

Independent Living Preparation

Parent Training

Building Transition Systems:

Interorganizational Linkages,

Opportunities & Youth Outcomes

A Study of the Child to Adult Transition Network for Clark County,

Washington

PART III:

Respondent’s Organization: _________________________________

Wave ●

ID

# Respondents

SECTION 3A: SERVICE SYSTEM EVALUATION-SYSTEM PERFORMANCE

The following questions ask you to describe and evaluate the system of services for 14-25 year olds who have developed serious emotional disturbance or serious mental illness and been served as youth by the Clark County Regional Support Network. We’ll refer to services for these individuals when they are 14-25 years of age as “transition services” and we’ll call these individuals “youth with SED”.

3.01 What transition services does your agency/program provide to youth with SED?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

3.02 Within your agency/program, have services or approaches been developed to respond to the specific needs of youth with SED during transition ages?

1….Yes 0…..No

(if no, skip to 3.03)

3.02a What have been the improvements? (including service continuity as they age from child to adult status, and the unique developmental tasks of this age group)

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

3.02b What have been the problems?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

3.03 Within Clark County, how well does the service delivery system work together to provide transition services for youth with SED? [show card]

Very well Very poorly

1 2 3 4 5

3.04 In what ways do agencies and programs cooperate and coordinate their transition services for this population?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

3.05 What are the major obstacles or barriers to cooperation and coordination of transition services for this population?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

3.06 What would it take to overcome these obstacles or barriers?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

3.07 Are there exemplary transition services, programs or strategies for meeting the needs of youth with SED in Clark County?

1….Yes 0…..No

(if no, skip to 3.08)

3.07a If so, please describe these transition services, programs or strategies.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

3.08 Are you aware of individuals in Clark County who are emerging as leaders in improving the system’s ability to serve youth with SED in transition?

1….. Yes 0…. No

(if no, skip to 3.03)

3.08a If yes, please identify these individuals and describe in what ways they are providing leadership. (if affiliated with an organization be sure to get name of organization)

NAME ORGANIZATIONAL AFFILIATION (IF ANY)

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

ID ___ ___ ___

SECTION 3B: PROGRAM EVALUATION-PERFORMANCE RATINGS

Rate your program/agency’s transition services during the past fiscal year (2002-2003). Transition services are services for 14-25 year olds that help them with age appropriate functioning, such as finishing school, getting a job, or staying out of trouble with the law. Transition services address these needs directly, as in vocational counseling, or indirectly, as in psychotherapy that helps individuals function better in general. Please answer the following question using the response scale provided.

How well do your transition services for youth with SED perform according to the following criteria?	Very Fairly Adequately Fairly Very Don’t Well Well Poorly Poorly Know 1 2 3 4 5 DK
AVAILABILITY
3.09 Avoiding excessive waiting lists or long delays in scheduling transition services…………………	1	2	3	4	5	DK	NA
3.10 Keeping “red tape” to a minimum in enrolling youth with SED into transition services….……	1	2	3	4	5	6	NA
3.11 Providing transportation to transition programs and services……………………………...…….	1	2	3	4	5	6	NA
3.12 Developing individualized transition services or programs for youth with SED…………..……..	1	2	3	4	5	6	NA
ACCESSIBILITY
3.13 Placing transition services and supports in accessible locations for youth with SED……...	1	2	3	4	5	6	NA
3.14 Providing transition services and supports at reasonable cost to youth with SED………..…..	1	2	3	4	5	6	NA
3.15 Preventing “creaming” the higher functioning or less challenging youth, leaving lower functioning or more challenging youth at risk……………….	1	2	3	4	5	6	NA
3.16 Ensuring that youth continue to access appropriate services when their change in age signifies a change in legal or eligibility status….	1	2	3	4	5	6	NA
3.17 Providing “unconditional” services and supports despite authority-testing, experimenting or other concerning behavior………………...……….	1	2	3	4	5	6	NA
COORDINATION
3.18 Fostering a “big Picture” understanding of the service system that provides elements of transition supports for youth with SED in Clark County and the roles and responsibilities of the agencies that constitute that system……………..	1	2	3	4	5	6	NA
3.19 Ensuring that other agencies have timely access to client records in ways that do not violate client confidentiality or the rights of clients…………….	1	2	3	4	5	6	NA
3.20 Ensuring meaningful discharge planning that links youth with appropriate services and supports and completed in sufficient time for those linkages to be successful……………………….	1	2	3	4	5	6	NA

How well do your transition services for youth with SED perform according to the following criteria?	Very Fairly Adequately Fairly Very Don’t Well Well Poorly Poorly Know 1 2 3 4 5 DK
QUALITY OF CARE
3.21 Making youth with SED ages 14-25 feel welcome and at ease in services settings………..……	1	2	3	4	5	6	NA
3.22 Giving priority to transition services for youth with SED……………………………….…….	1	2	3	4	5	6	NA
3.23 Establishing grievance mechanisms for youth with SED ages 14-25………………………	1	2	3	4	5	6	NA
3.24 Attracting people of different backgrounds to participate in community-wide planning of transition services……………………….…..…	1	2	3	4	5	6	NA
3.25 Emphasizing the strengths of youth with SED during transition ages 14-25…………………..	1	2	3	4	5	6	NA
3.26 Ensuring that transition services are developmentally appropriate for this age group…	1	2	3	4	5	6	NA
3.27 Developing formal mechanisms for input from youth with SED ages 14-25 into program development, policies, and practices…………..	1	2	3	4	5	6	NA
3.28 Having individual clients aged 14-25 lead his/her own transition planning process…………..……	1	2	3	4	5	6	NA
3.29 Developing transition supports and services that are appealing to youth with SED aged 14-25…..	1	2	3	4	5	6	NA
3.30 Offer transition supports and services that address the needs of youth across the complete array of life domains (i.e. housing, vocation, education, MH or SA treatment, social skills etc.)…………	1	2	3	4	5	6	NA
3.31 Providing outreach to youth with SED aged 14-25 who may be reticent to engage in services………………………………………..	1	2	3	4	5	6	NA

ID ___ ___ ___

SECTION 3C: SYSTEM EVALUATION-PERFORMANCE RATINGS

Rate the entire range of transition services provided in Clark County during the past fiscal year (2002-2003) Please answer the following question using the response scale provided.

How well do Clark County transition services for youth with SED perform according to the following criteria?	Very Fairly Adequately Fairly Very Don’t Well Well Poorly Poorly Know 1 2 3 4 5 DK
AVAILABILITY
3.32 Avoiding excessive waiting lists or long delays in scheduling transition services………………	1	2	3	4	5	DK	NA
3.33 Keeping “red tape” to a minimum in enrolling youth with SED into transition services………	1	2	3	4	5	6	NA
3.34 Providing transportation to transition programs and services……………………………..…….	1	2	3	4	5	6	NA
3.35 Developing individualized transition services or programs for youth with SED………………..	1	2	3	4	5	6	NA
ACCESSIBILITY
3.36 Placing transition services and supports in accessible locations for youth with SED……..	1	2	3	4	5	6	NA
3.37 Providing transition services and supports at reasonable cost to youth with SED……….….	1	2	3	4	5	6	NA
3.38 Providing transition services and supports at reasonable cost to Clark County programs..	1	2	3	4	5	6	NA
3.39 Preventing “creaming” the higher functioning or less challenging youth, leaving lower functioning or more challenging youth at risk……………..	1	2	3	4	5	6	NA
3.40 Ensuring that youth continue to access appropriate services when their change in age signifies a change in legal or eligibility status…..	1	2	3	4	5	6	NA
3.41 Providing “unconditional” services and supports despite authority-testing, experimenting or other concerning behavior…………………………….	1	2	3	4	5	6	NA
COORDINATION
3.42 Using a common intake form for basic client information across mental health, developmental disabilities, substance abuse, vocational, housing, health, school-based, and social service agencies……………………………………….…	1	2	3	4	5	6	NA
3.43 Using a common triage form for clinical information across mental health, developmental disabilities, substance abuse, vocational, housing, health, school-based, and social service agencies…………………………………..…..…..	1	2	3	4	5	6	NA

How well do your transition services for youth with SED perform according to the following criteria?	Very Fairly Adequately Fairly Very Don’t Well Well Poorly Poorly Know 1 2 3 4 5 DK
COORDINATION con’t
3.44 Using a single transition plan that focuses on the goals of young adult functioning and supports from mental health, developmental disabilities, substance abuse, vocational, housing, health, school-based, and social service agencies to achieve those goals……………………...……	1	2	3	4	5	6	NA
3.45 Fostering a “big Picture” understanding of the service system that provides elements of transition supports for youth with SED in Clark County and the roles and responsibilities of the agencies that constitute that system…………..	1	2	3	4	5	6	NA
3.46 Ensuring that other agencies have timely access to client records in ways that do not violate client confidentiality or the rights of clients………….	1	2	3	4	5	6	NA
3.47 Ensuring meaningful discharge planning that links youth with appropriate services and supports and completed in sufficient time for those linkages to be successful…………………………	1	2	3	4	5	6	NA
QUALITY OF CARE
3.48 Making youth with SED ages 14-25 feel welcome and at ease in services settings…………………	1	2	3	4	5	6	NA
3.49 Giving priority to transition services for youth with SED……………………………………….	1	2	3	4	5	6	NA
3.50 Establishing grievance mechanisms for youth with SED ages 14-25…………………………….	1	2	3	4	5	6	NA
3.51 Attracting people of different backgrounds to participate in community-wide planning of transition services………………………………	1	2	3	4	5	6	NA
3.52 Emphasizing the strengths of youth with SED during transition ages 14-25……………………..	1	2	3	4	5	6	NA
3.53 Ensuring that transition services are developmentally appropriate for this age group…	1	2	3	4	5	6	NA
3.54 Developing formal mechanisms for input from youth with SED ages 14-25 into program development, policies, and practices……………..	1	2	3	4	5	6	NA
3.55 Having individual clients aged 14-25 lead his/her own transition planning process…………………	1	2	3	4	5	6	NA
3.56 Developing transition supports and services that are appealing to youth with SED aged 14-25…..	1	2	3	4	5	6	NA
3.57 Offer transition supports and services that address the needs of youth across the complete array of life domains (i.e. housing, vocation, education, MH or SA treatment, social skills etc.)…………	1	2	3	4	5	6	NA
3.58 Providing outreach to youth with SED aged 14-25 years who may be reticent to engage in services…	1	2	3	4	5	6	NA

SECTION 3D: CLOSING COMMENTS

9. Please add any additional comments about Clark County transition services for youth with SED, networking services, and coordination of services below:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

SECTION 4: DEMOGRAPHIC INFORMATION

1. Age: ___ ___ (years)

2. Sex (circle response): 0…. Male 1…. Female

3. Race (circle response): 0…. White 1…. Black or African American 2…….Native Hawaiian or other Pacific Islander 3…..Asian. 4…….American Indian or Alaska Native 5…. Other ______________________

4. Ethnicity (circle response): 0….Non-Hispanic 1….. Hispanic

5. How long have you worked in human services/education/social services? ___ ___ years

6. How long have you worked in your current position? ___ ___ years ___ ___ months

7. What is your educational background?

___ Clinical Psychologist ___ M.D.

___ Masters Level Social Work ___ Nursing

___ MBA ___ Bachelor’s Arts/Sciences

___ Masters level Public Admin. ___ Bachelor’s Business

___ Other ____________________________________________________________________

Thank you for your time.

Indicate if requested copy of final report: Yes No

Finish Time: _____________________

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