ADHD Treatment, Cost, and Client Satisfaction Questionna

OMB No: ???: Exp Date: ???

_____________________

ADHD Treatment, Cost, and Client Satisfaction Questionnaire

ADHD Treatment

1 . Has your child been diagnosed with any of the following? (Select all that apply)

• social phobia

• generalized anxiety

• tics

• obsessive compulsive disorder

• separation anxiety

• mutism

• pica

• conduct disorder

• specific phobia

• obsessive compulsive disorder

• trichotillomania

• other

• panic disorder

• post traumatic stress disorder

• depression

• attention deficit hyper-activity disorder

• agoraphobia

• elimination disorder

• mania

If you selected ADHD (attention deficit hyper-activity disorder) above please complete the remaining form.

2 . When was your child diagnosed with ADHD?

• NA Month Year

• D on’t Know

2a. Who diagnosed your child with ADHD? Name Profession:

• Not applicable

• Missing/ Don’t Know

2 b. Where (city) is this professional located?

3. Are you affiliated with a support group for your child’s condition?

• No

• Y es

If yes, please list support groups:

4. Has your child received medication as part of his/her treatment in the past 12 months?

• N o

• Yes

4a. If yes, was any of the cost covered by insurance?

• No

• Yes

4 b. (enter average monetary cost) $

4c. Who administers the medication to your child? Select all that apply

O Parent

O School Nurse/Personnel/Other

O Child

Public reporting burden of this collection of information is estimated to average 10 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 Information Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA ???).

4d. How many medications has your child taken in the past 12 months?

P lease list below:

Medication 1: Start Date Month Day Year E nd Date Month Day Year Dosage: 1 x day 2 x daily 3 x daily 5 days/wk 7 days/wk H ow many mg per day? ___ Is this the prescribed amount? O Yes O No, child is taking more O No, child is taking less W hat was the cost to you? $ Does your child take this medication in the summer? O No O Yes For what problem was the medication given? Do you think the medication helped? O No O Yes Why did he/she stop?

Medication 2: S tart Date Month Day Year E nd Date Month Day Year Dosage: 1 x day 2 x daily 3 x daily 5 days/wk 7 days/wk H ow many mg per day? ___ Is this the prescribed amount? O Yes O No, child is taking more O No, child is taking less W hat was the cost to you? $ Does your child take this medication in the summer? O No O Yes For what problem was the medication given? Do you think the medication helped? O No O Yes Why did he/she stop?

Medication 3: Start Date Month Day Year E nd Date Month Day Year Dosage: 1 x day 2 x daily 3 x daily 5 days/wk 7 days/wk H ow many mg per day? ___ Is this the prescribed amount? O Yes O No, child is taking more O No, child is taking less W hat was the cost to you? $ Does your child take this medication in the summer? O No O Yes For what problem was the medication given? Do you think the medication helped? O No O Yes Why did he/she stop?

Medication 4: S tart Date Month Day Year E nd Date Month Day Year Dosage: 1 x day 2 x daily 3 x daily 5 days/wk 7 days/wk H ow many mg per day? ___ Is this the prescribed amount? O Yes O No, child is taking more O No, child is taking less W hat was the cost to you? $ Does your child take this medication in the summer? O No O Yes For what problem was the medication given? Do you think the medication helped? O No O Yes Why did he/she stop?

5. Has your child taken dietary supplements (vitamins and/or herbs) as part of his/her treatment in the past 12 months?

O No

O Yes

5 a. If yes, How many?

5 b. What was the cost to you? (enter average monetary cost) $

5c. Please list (zinc, chamomile, kava hops, lemon balm, valerian root, passionflower, melatonin, ginko biloba, pycnogenol, nystatin, ketonazole, piracetam, dimethylaminoethanol, linoleic, linolenic acids, megavitamins):

V itamin 1: How many mg per day? V itamin 2: How many mg per day?

V itamin 3: How many mg per day? V itamin 4: How many mg per day?

6. In the past year, have you received parent training as related to the child’s treatment? (parent training includes: counseling, behavior modification training, or other parent training)

• No

• Y es

6a. If yes, Provided by:

• School

• Mental Health Provider

• Physician / Pediatrician

• Other

6b. Was it for:

• ADHD

• Other ___________________

6 c. Number of times hours

6d. Was any of the cost covered by insurance?

• No

• Yes

6 e. What was the cost to you? (enter average monetary cost) $

7 . In the past 12 months, has your child received social skills training as related to his/her treatment?

• No

• Yes

7a. If yes, Provided by:

• School

• Mental Health Provider

• Physician / Pediatrician

• Other

7b. Was it for:

• A DHD

• Other ___________________

7 c. Number of times hours

7d. Was any of the cost covered by insurance?

• No

• Yes

7 e. What was the cost to you? (enter average monetary cost) $

8 . In the past 12 months, has your child received school or classroom programs as related to his/her treatment? (school or classroom programs include: classroom modifications, preferential seating, testing accommodations, and behavior management plans applied in the classroom or school)

• No

• Yes

8a. If yes, Provided by:

• Teacher

• School Counselor/Psychologist

• Other ___________________

8b. Was it for:

• ADHD

• Other ___________________

8 c. Number of times hours

8d. Was any of the cost covered by insurance?

• No

• Yes

8 e. What was the cost to you? (enter average monetary cost) $

9. In the past 12 months, has your child received counseling as related to his/her treatment?

• N o

• Yes

9a. If yes, Provided by:

• School

• Mental Health Provider

• Physician / Pediatrician

• Other

9b. Was it for:

• ADHD

• Other ___________________

9 c. Number of times hours

9 d. Type:

• Individual

• Group

9e. Was any of the cost covered by insurance?

• No

• Yes

9 f. What was the cost to you? (enter average monetary cost) $

10. In the past year, has your child made dietary changes as related to the child’s treatment?

• N o

• Yes

10a.If yes, Provided by:

• School

• Mental Health Provider

• Physician / Pediatrician

• Other

1 0b.Time on diet (months)

10c.Was it for:

• ADHD

• Other ___________________

1 0d.Type of diet

1 1. In the past year, has your child received “alternative” services (i.e. EEG biofeedback or sensory integration) as related to his/her treatment?

• No

• Yes

11a. If yes, list below:

11b. Provided by:

• School

• Mental Health Provider

• Physician / Pediatrician

• Other

1 1c. Number of times hours

11d. Was any of the cost covered by insurance?

• No

• Yes

1 1e. What was the cost to you? (enter average monetary cost) $

This section for Annual Assessments Only

MEDICATIONS
1. In the past 12 months, has your child ever used too much of his/her medication? (If NO, go to question 2)	Yes No
If yes, did he/she have to get medical care?	Yes No
If yes, did he/she have to go to the emergency room?	Yes No
2. In the past 12 months, has your child ever stopped taking his/her medication because of a side effect or negative reaction?	Yes No
TREATMENT COSTS
3. During the past 12 months, how much has your family paid out-of-pocket for your child's health related needs?	Nothing, $0 Less than $250 $250-$500 More than $500
4. Did you ever stop a treatment or decide not to buy a medication for your child’s condition because it was too expensive?	Yes No
5. Has your child's health condition(s) caused financial problems for the family?	Yes No
6. How many hours a month do you or other family members spend taking your child to the doctor or to receive treatments, counseling, training, etc.?	hours
Note: Please answer the next 4 questions if your child is currently covered by some form of health insurance.
7. Does your child’s health insurance offer benefits that meet his/her needs?	Never Sometimes Usually Always
8. Are the costs not covered by your child’s health insurance reasonable?	Never Sometimes Usually Always
9. Does the health insurance company allow your child to see the health care providers he/she needs?	Never Sometimes Usually Always
10. Does the health insurance company cover all the treatments recommended by your doctor or health care provider?	Never Sometimes Usually Always

CSQ-8: Now we would like to learn how satisfied you have been with the services your child has received in the last twelve months: Please respond to each category of treatment you or your child has received.
	Medical Services	Psychological/ Behavioral	School Services
1. How would you rate the quality of service your child has received?	O Poor O Fair O Good O Excellent	O Poor O Fair O Good O Excellent	O Poor O Fair O Good O Excellent
2. Did your child get the kind of service you wanted?	O No, definitely not O No, not really O Yes, generally O Yes, definitely	O No, definitely not O No, not really O Yes, generally O Yes, definitely	O No, definitely not O No, not really O Yes, generally O Yes, definitely
3. To what extent has this service met your child’s needs?	O None of my child’s needs have been met O Only a few of my child’s needs have been met O Most of my child’s needs have been met O Almost all of my child’s needs have been met	O None of my child’s needs have been met O Only a few of my child’s needs have been met O Most of my child’s needs have been met O Almost all of my child’s needs have been met	O None of my child’s needs have been met O Only a few of my child’s needs have been met O Most of my child’s needs have been met O Almost all of my child’s needs have been met
4. If a friend were in need of similar help, would you recommend this service to his or her family?	O No, definitely not O No, I don’t think so O Yes, I think so O Yes, definitely	O No, definitely not O No, I don’t think so O Yes, I think so O Yes, definitely	O No, definitely not O No, I don’t think so O Yes, I think so O Yes, definitely
5. How satisfied are you with the amount of help your child has received?	O Quite dissatisfied O Indifferent/mildly satisfied O Mostly satisfied O Very satisfied	O Quite dissatisfied O Indifferent/mildly satisfied O Mostly satisfied O Very satisfied	O Quite dissatisfied O Indifferent/mildly satisfied O Mostly satisfied O Very satisfied
6. Have the services your child received helped him/her to deal more effectively with problems?	O No, they seemed to make things worse O No, they really didn’t help O Yes, they helped somewhat O Yes, they helped a great deal	O No, they seemed to make things worse O No, they really didn’t help O Yes, they helped somewhat O Yes, they helped a great deal	O No, they seemed to make things worse O No, they really didn’t help O Yes, they helped somewhat O Yes, they helped a great deal
7. In an overall, general sense, how satisfied are you with the service your child has received?	O Quite dissatisfied O Indifferent/mildly satisfied O Mostly satisfied O Very satisfied	O Quite dissatisfied O Indifferent/mildly satisfied O Mostly satisfied O Very satisfied	O Quite dissatisfied O Indifferent/mildly satisfied O Mostly satisfied O Very satisfied
8. If you were to seek help for your child again, would you return to this service?	O No, definitely not O No, I don’t think so O Yes, I think so O Yes, definitely	O No, definitely not O No, I don’t think so O Yes, I think so O Yes, definitely	O No, definitely not O No, I don’t think so O Yes, I think so O Yes, definitely
Copyright © 1989, 1990. Clifford Attkisson, Ph.D. Used with written permission. Reproduction in whole or in part is forbidden without the authors’ written permission. UCSF University of California, San Francisco.

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