School Mental Health and Social Services

Mental Health and Social Services Coordinator

Form Approved

OMB No: 0920-0445

Expiration Date: xx/xx/xxxx

Mental Health and Social Services
School Questionnaire

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Public reporting burden for this collection of information is estimated to average 30 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 Reports Clearance Officer, 1600 Clifton Road NE, Mailstop D-74, Atlanta, GA 30333; Attention PRA (0920-0445).

Mental Health and Social Services
School Questionnaire

Questions

Job Title 1

Staffing Characteristics 2–18

Collaboration and Promotion 19–22

Facilities and Equipment 23–24

Provision of Mental Health and Social Services 25–35

Services Provided at Other Sites 36–39

Mental Health and Social Services Coordinator 40–56

NOTE: THROUGHOUT THIS QUESTIONNAIRE, TEXT THAT APPEARS IN ALL CAPITAL LETTERS WILL NOT BE READ ALOUD TO RESPONDENTS.

THIS QUESTIONNAIRE WILL BE ADMINISTERED USING COMPUTER ASSISTED PERSONAL INTERVIEW TECHNOLOGY. THE INTERVIEWER WILL READ THE QUESTIONS ALOUD AND TYPE RESPONSES TO THE QUESTIONS INTO THE LAPTOP COMPUTER. THE INTERVIEW PROGRAM WILL 1) DISPLAY THE CORRECT TENSE OF VERBS, 2) PROVIDE ALTERNATE ANSWERS TO QUESTIONS (E.G., NOT APPLICABLE, “I DON’T KNOW”), 3) NAVIGATE COMPLEX SKIP PATTERNS, AND 4) PERFORM OTHER USEFUL FUNCTIONS. COMMENTS APPEARING IN THE MARGIN REPRESENT ASSISTANCE AVAILABLE TO THE RESPONDENT IF ADDITIONAL CLARIFICATION IS REQUIRED ON THE QUESTION OR THE SPECIFIC TERMINOLOGY USED. WHEN ASKED, THE INTERVIEWER WILL READ THESE STATEMENTS ALOUD TO THE RESPONDENT. THE PROGRAMMING SPECIFICATIONS FOR THE INTERVIEW ARE NOT INCLUDED IN THIS PRINTED VERSION OF THE QUESTIONNAIRE.

1. What is your job title at the school? (In which role do you spend more time?)

1) Principal 2) Asst. Principal/Other School Administrator 3) School Secretary 4) Physical Ed Teacher 5) Athletic Director 6) Health Ed Teacher 7) Other Teacher 8) Food Service Manager 9) Commercial Food Service Provider 10) Other School Food Service Staff 11) School Counselor

12) Social Worker 13) Psychologist 14) Other Mental Health/ Social Services Provider 15) Nurse 16) Health Aide 17) Physician 18) Other Health Services Provider 19) SBHC Health Services Staff 20) SBHC Mental Health/ Social Services Staff 50) Other Staff

This interview asks about standard mental health and social services. By “standard,” we mean services available to all students at your school. Mental health and social services include services such as crisis intervention, identification of emotional disorders, or assistance with enrolling in Medicaid. These services usually are provided by a school counselor, psychologist, or social worker but also could be provided at your school by staff from collaborating community agencies.

First, I would like to ask questions about staffing for standard mental health and social services at your school. Please include both contracted providers and regular school staff.

2. Is there a part-time or full-time school counselor who provides standard mental health or social services to students at your school? Do not include school counselors who provide only academic counseling or college or career placement.

Yes 1

No 2 SKIP TO Q5

3. How many part-time or full-time school counselors provide standard mental health or social services to students at your school?

Counselors

4. During the past 30 days, how many hours per week on average has each school counselor spent at your school?

Counselor 1 Hours/Week

Counselor 2 Hours/Week

Counselor 3 Hours/Week

Counselor 4 Hours/Week

5. At your school, what is the minimum level of education required for a newly hired school counselor?

Undergraduate degree in counseling 1

Master’s degree in counseling 2

Other degree (Specify) 3

No specific education requirement 4

6. Is a newly hired school counselor required to be licensed, certified, or credentialed by a state agency or board?

Yes 1

No 2

State does not license, certify, or credential
school counselors 3

7. Is there a part-time or full-time school psychologist who provides standard mental health or social services to students at your school? Do not include school psychologists who only conduct psychological testing.

Yes 1

No 2 SKIP TO Q10

8. How many part-time or full-time school psychologists provide standard mental health or social services to students at your school?

Psychologists

9. During the past 30 days, how many hours per week on average has each school psychologist spent at your school?

Psychologist 1 Hours/Week

Psychologist 2 Hours/Week

Psychologist 3 Hours/Week

Psychologist 4 Hours/Week

10. At your school, what is the minimum level of education required for a newly hired school psychologist?

Undergraduate degree in psychology 1

Master’s degree in psychology 2

Doctorate in psychology 3

Other degree (Specify) 4

No specific education requirement 5

11. Is a newly hired school psychologist required to be licensed, certified, or credentialed by a state agency or board?

Yes 1

No 2

State does not license, certify,
or credential school psychologists 3

12. Is there a part-time or full-time school social worker who provides standard mental health or social services to students at your school?

Yes 1

No 2 SKIP TO Q15

13. How many part-time or full-time school social workers provide standard mental health or social services to students at your school?

Social workers

14. During the past 30 days, how many hours per week on average has each school social worker spent at your school?

Social worker 1 Hours/Week

Social worker 2 Hours/Week

Social worker 3 Hours/Week

Social worker 4 Hours/Week

15. At your school, what is the minimum level of education required for a newly hired school social worker?

Undergraduate degree in social work 1

Master’s degree in social work 2

Other degree (Specify) 3

No specific education requirement 4

16. Is a newly hired school social worker required to be licensed, certified, or credentialed by a state agency or board?

Yes 1

No 2

State does not license, certify,
or credential school social workers 3

17. Are all school mental health or social services staff required to earn continuing education credits on mental health or social services topics?

Yes 1

No 2

IF THERE IS NO SCHOOL COUNSELOR, PSYCHOLOGIST, OR SOCIAL WORKER AT THIS SCHOOL (Q2, Q7, AND Q12 ARE “NO”), SKIP TO THE INTRODUCTION TO Q21.

18. During the past 12 months, has a school counselor, psychologist, or social worker at your school talked to or taught…

Yes No

ANSWER A AND B FOR MIDDLE AND HIGH SCHOOL ONLY.
OTHERWISE, SKIP TO THE INSTRUCTIONS BEFORE C.

1. A health education class at your school? 1 2

2. Any other class at your school? 1 2

ANSWER C AND D FOR ELEMENTARY SCHOOL ONLY.
OTHERWISE, SKIP TO THE INTRODUCTION TO Q19.

3. Students at your school as part of a health education
   lesson or unit? 1 2

4. Students at your school as part of any other lesson or unit? 1 2

Now I’m going to ask you about collaboration among mental health or social services staff and other school and local agency staff.

19a. During the past 12 months, has a school counselor, psychologist, or social worker at your school worked on standard school mental health or social services activities with health education staff from your school?

Yes 1

No 2

School does not have health education staff 3

19b. What about with physical education staff from your school?

Yes 1

No 2

School does not have physical education staff 3

19c. What about with nutrition or food service staff from your school?

Yes 1

No 2

School does not have nutrition or
food service staff 3

19d. What about with health services staff from your school?

Yes 1

No 2

School does not have health services staff 3

19e. School-based health center staff from your school?

Yes 1

No 2

School does not have school-based
health center staff 3

20. During the past 12 months, has a school counselor, psychologist, or social worker worked on standard school mental health or social services activities for students with staff or members from…

Yes No

1. A health organization, such as the American Heart
   Association or the American Red Cross? 1 2

2. A local health department? 1 2

3. A local mental health or social services agency? 1 2

4. A local juvenile justice department? 1 2

5. A local college or university? 1 2

6. A local business? 1 2

7. A local child welfare agency? 1 2

8. A local hospital? 1 2

9. A local law enforcement agency? 1 2

10. A local service club, such as the Rotary Club? 1 2

11. Communities in Schools? 1 2

The next question asks whether certain groups have helped develop, communicate, or implement mental health or social services policies or activities. Examples of this might include sitting on a committee, presenting to the school board, organizing a school-wide event, or soliciting or providing donations for school mental health or social services.

19. During the past two years, have any of the following groups helped develop, communicate, or implement mental health or social services policies or activities?

Yes No

1. Students 1 2

2. Students’ families 1 2

3. Teachers 1 2

4. Other community members 1 2

20. During the past 12 months, has anyone from your school…

Yes No N/A

1. Met with a parents’ organization, such as
   the PTA, to discuss standard school
   mental health and social services? 1 2

2. Provided families of all students with
   information on standard school
   mental health and social services? 1 2

3. Invited family members of all students to
   tour the standard mental health and social
   services facilities? 1 2 3

4. Collected suggestions from students about
   school mental health and social services? 1 2

5. Collected suggestions from students’
   families about school mental health and
   social services? 1 2

The next question asks about facilities and equipment that might be available for mental health or social services staff at your school to use.

21. Does your school have…

Yes No

1. A private room for counseling students? 1 2

2. A dedicated phone line for standard mental health
   or social services staff? 1 2

3. An answering machine or voice mail reserved for
   standard mental health or social services staff? 1 2

4. Locked storage space for files related to the standard
   mental health or social services provided to students? 1 2

22. Where in relation to your school’s main office is the primary location where students go to obtain standard mental health or social services? Are the services offered…

Within the same office suite as the
main office, 1

Within view of the main office, or 2

Not within view of the main office? 3

I am going to ask about the activities of mental health or social services staff such as school counselors, psychologists, and social workers. Please do not include activities by teachers in the classroom or activities by nurses or physicians. I’ll find out about their activities during a different interview.

SHOW CARD 1

As I read the list on this card, please tell me if each is provided by mental health or social services staff to students at your school.

23. Do mental health or social services staff provide…

Yes No

1. Case management for students with emotional or
   behavioral problems? 1 2

2. Family counseling? 1 2

3. Group counseling? 1 2

4. Individual counseling? 1 2

5. Comprehensive assessment or intake evaluation? 1 2

6. Peer counseling or mediation? 1 2

7. Self-help or support groups? 1 2

IF Q25A–G ARE ALL “NO” SKIP TO THE INTRODUCTION TO Q28.

24. Who provides [each service listed in Q25A–G]?
    MARK ALL THAT APPLY

School counselor 1

School psychologist 2

School social worker 3

Other (Specify) 4

25. At your school, how are standard mental health and social services funded?
    MARK ALL THAT APPLY

School district budget 1

Medicaid 2

State Children’s Health Insurance Program
(SCHIP) 3

Private insurance 4

Public grants 5

Private grants 6

Other 7

Student assistance programs provide services designed to assist students experiencing personal or social problems that can impact school performance, physical health, or overall well-being.

26. Is a student assistance program offered to students at your school?

Yes 1

No 2

Some schools have a team of school staff who collaborate to provide assistance to students with disabilities or those who are experiencing academic difficulties or behavioral problems. These sometimes are called student support teams, student assistance teams, or student guidance teams.

27. Does your school have such a team?

Yes 1

No 2 àSKIP TO THE INSTRUCTIONS BEFORE Q31

28. Does this team include staff from collaborating community agencies?

Yes 1

No 2

IF THIS IS A PRIVATE OR CATHOLIC SCHOOL, SKIP TO Q34.

29. Does someone from the mental health and social services staff participate in the development of Individualized Education Programs, or IEPs, when indicated?

Yes 1

No 2

30. Does someone from the mental health and social services staff participate in the development of Individualized Health Plans, or IHPs, when indicated?

Yes 1

No 2

31. Does someone from the mental health and social services staff participate in the development of 504 plans, when indicated?

Yes 1

No 2

32. During the past 12 months, has your school reviewed mental health or social services records to identify students with chronic mental health or social services problems or ways to prevent further occurrences of these problems?

Yes 1

No 2

School does not keep mental health
or social services records 3

33. Is there backup or after hours coverage when school mental health or social services staff are unavailable, for example after school or on weekends?

Yes 1

No 2

This next set of questions asks about mental health or social services delivered to students or families from your school at other sites not on school property regardless of whether the services are paid for by the school system. These services may be provided by mental health or social services professionals who work at school-linked health centers or who have a contract, memorandum of agreement, or other similar arrangement with the district or school to provide mental health or social services to students or families.

34. Currently, do any organizations or mental health or social services professionals have a contract, memorandum of agreement, or other similar arrangement to provide mental health or social services to students or families from your school?

Yes 1

No 2 SKIP TO Q40

SHOW CARD 2

35. Which of the organizations or mental health or social services professionals listed on this card have arrangements to provide mental health or social services to students or families from your school?
    MARK ALL THAT APPLY

A school-linked health center 1

A community health clinic or health center 2

A local health department 3

A local hospital 4

A local mental health or social services
agency 5

A university, medical school, or
nursing school 6

A managed care organization 7

A private psychologist 8

A private psychiatrist 9

A private social worker 10

A private counselor 11

SHOW CARD 3

As I read the list printed on this card, please tell me if there are arrangements with any organizations or mental health or social services professionals to provide these services to students or families from your school.

36. Are there arrangements with any organizations or mental health or social services professionals to provide…

Yes No

ANSWER A AND B FOR MIDDLE AND HIGH SCHOOL ONLY.
OTHERWISE, SKIP TO C.

1. Tobacco use cessation? 1 2

2. Alcohol or other drug use treatment? 1 2

3. Counseling after a natural disaster or other emergency
   or crisis situation? 1 2

4. Crisis intervention for personal problems? 1 2

5. Identification of emotional or behavioral disorders,
   such as anxiety, depression, or ADHD? 1 2

6. Counseling for emotional or behavioral disorders,
   such as anxiety, depression, or ADHD? 1 2

7. Stress management? 1 2

8. Weight management? 1 2

ANSWER I AND J FOR MIDDLE AND HIGH SCHOOL ONLY.
OTHERWISE, SKIP TO K.

9. Identification of or referral for eating disorders? 1 2

10. HIV counseling, testing, and referral? 1 2

11. Identification of or referral for physical, sexual, or
    emotional abuse? 1 2

12. Identification of or referral for students
    with family problems, such as parental divorce,
    substance abuse, or violence? 1 2

13. Referrals for after-school programs for students,
    such as supervised recreation? 1 2

(Q38 continued)

Yes No

ANSWER N, O AND P FOR MIDDLE AND HIGH SCHOOL ONLY.
OTHERWISE, SKIP TO Q.

14. Referrals for child care for teen mothers? 1 2

15. Services specifically for gay, lesbian,
    or bisexual students? 1 2

16. Job readiness skills programs? 1 2

17. Assistance with enrolling in WIC or accessing
    food stamps or food banks? 1 2

18. Assistance with securing temporary or permanent housing? 1 2

19. Assistance with enrolling in Medicaid or SCHIP? 1 2

20. Assistance for accessing benefits for students
    with disabilities? 1 2

SHOW CARD 4

As I read the list on this card, please tell me if there are arrangements with any organizations or mental health or social services professionals to provide to these services to students or families from your school.

37. Are there arrangements with any organizations or mental health or social services professionals to provide…

Yes No

1. Case management for students with emotional or
   behavioral problems? 1 2

2. Family counseling? 1 2

3. Group counseling? 1 2

4. Individual counseling? 1 2

5. Comprehensive assessment or intake evaluation? 1 2

6. Peer counseling or mediation? 1 2

7. Self-help or support groups? 1 2

38. Currently, does someone at your school oversee or coordinate standard mental health and social services?

Yes 1

No 2 SKIP TO Q56

39. Are you this person?

Yes 1

No 2  SKIP TO Q56

SHOW CARD 5

40. Please tell me who you work for.
    MARK ALL THAT APPLY

School district 1

This school 2

A local mental health or social services
agency 3

Other 4

Now, I’d like to ask you some questions about your educational background.

41. Do you have an undergraduate degree?

Yes 1

No 2 SKIP TO THE INTRODUCTION TO Q50

42. What did you major in?
    MARK ALL THAT APPLY

Counseling 1

Psychology 2

Social work 3

Education 4

Other (Specify) 5

43. Did you have an undergraduate minor?

Yes 1

No 2 SKIP TO Q47

44. What did you minor in?
    MARK ALL THAT APPLY

Counseling 1

Psychology 2

Social work 3

Education 4

Other (Specify) 5

45. Do you have a graduate degree?

Yes 1

No 2 SKIP TO Q49

46. In what area or areas was your graduate work?
    MARK ALL THAT APPLY

Counseling 1

Psychology 2

Social work 3

Education 4

Other (Specify) 5

47. Are you currently licensed, certified, or credentialed by a state agency or board to provide school mental health or social services?

Yes 1

No 2

State does not license, certify,
or credential school mental health
or social services professionals 3

SHOW CARD 6

Finally, I’d like to ask you a few questions on professional development. This might include workshops, conferences, continuing education, graduate courses, or any other kind of in-service.

As I read the list of topics printed on this card, please tell me if you received any professional development on each topic during the past two years.

48. During the past two years, did you receive any professional development on…

Yes No

1. Tobacco use cessation? 1 2

2. Alcohol or other drug use treatment? 1 2

3. Counseling after a natural disaster or other emergency
   or crisis situation? 1 2

4. Crisis intervention for personal problems? 1 2

5. Emergency preparedness? 1 2

6. Identification of emotional or behavioral disorders,
   such as anxiety, depression, or ADHD? 1 2

7. Counseling for emotional or behavioral disorders,
   such as anxiety, depression, or ADHD? 1 2

8. Stress management? 1 2

9. Weight management? 1 2

10. Identification of or referral for eating disorders? 1 2

11. HIV counseling, testing and referral? 1 2

12. Identification of or referral for physical, sexual, or
    emotional abuse? 1 2

13. Identification of or referral for students with
    family problems, such as parental divorce,
    substance abuse or violence? 1 2

14. After-school programs for students such as
    supervised recreation? 1 2

15. Child care options for teen mothers? 1 2

16. Services specifically for gay, lesbian, or bisexual students? 1 2

17. Enrolling in WIC or accessing food stamps or food banks? 1 2

18. Securing temporary or permanent housing? 1 2

19. Enrolling in Medicaid or SCHIP? 1 2

20. Accessing benefits for students with disabilities? 1 2

21. Job readiness skills programs? 1 2

SHOW CARD 6

49. Which of these topics would you like to receive further professional development on?
    MARK ALL THAT APPLY

Tobacco use cessation 1

Alcohol or other drug use treatment 2

Counseling after a natural disaster or other
emergency or crisis situation 3

Crisis intervention for personal problems 4

Emergency preparedness 5

Identification of emotional or behavioral
disorders, such as anxiety, depression,
or ADHD 6

Counseling for emotional or behavioral
disorders, such as anxiety, depression,
or ADHD 7

Stress management 8

Weight management 9

Identification of or referral for eating
disorders 10

HIV counseling, testing, and referral 11

Identification of or referral for physical,
sexual, or emotional abuse 12

Identification of or referral for students with
family problems, such as parental divorce,
substance abuse, or violence 13

After-school programs for students
supervised recreation 14

Child care options for teen mothers 15

Services specifically for gay, lesbian, or
bisexual students 16

Enrolling in WIC or accessing food stamps
or food banks 17

Securing temporary or permanent housing 18

Enrolling in Medicaid or SCHIP 19

Accessing benefits for students with
disabilities 20

Job readiness skills programs 21

None of these 22

SHOW CARD 7

50. During the past two years, have you received any professional development on…

Yes No

1. Nutrition and dietary behavior counseling? 1 2

2. Physical activity and fitness counseling? 1 2

3. Pregnancy prevention? 1 2

4. HIV prevention? 1 2

5. STD prevention? 1 2

6. Suicide prevention? 1 2

7. Tobacco use prevention? 1 2

8. Alcohol or other drug use prevention? 1 2

9. Violence prevention, for example bullying, fighting, or
   dating violence prevention? 1 2

10. Injury prevention and safety counseling? 1 2

SHOW CARD 7

51. Which of these topics would you like to receive further professional development on?
    MARK ALL THAT APPLY

Nutrition and dietary behavior counseling 1

Physical activity and fitness counseling 2

Pregnancy prevention 3

HIV prevention 4

STD prevention 5

Suicide prevention 6

Tobacco use prevention 7

Alcohol or other drug use prevention 8

Violence prevention, such as bullying,
fighting, or dating violence prevention 9

Injury prevention and safety counseling 10

None of these 11

SHOW CARD 8

52. Finally, during the past two years, have you received any professional development on…

Yes No

1. Case management for students with emotional or
   behavioral problems? 1 2

2. Family counseling? 1 2

3. Group counseling? 1 2

4. Individual counseling? 1 2

5. Comprehensive assessment or intake evaluation? 1 2

6. Peer counseling or mediation? 1 2

7. Self-help or support groups? 1 2

8. Student assistance programs? 1 2

9. Student support teams? 1 2

SHOW CARD 8

53. Which of these topics would you like to receive further professional development on?
    MARK ALL THAT APPLY

Case management for students with
emotional or behavioral problems 1

Family counseling 2

Group counseling 3

Individual counseling 4

Comprehensive assessment or
intake evaluation 5

Peer counseling or mediation 6

Self-help or support groups 7

Student assistance programs 8

Student support teams 9

None of these 10

54. My supervisor may wish to call you to ask about how I conducted this interview. Would you please tell me a telephone number where we might reach you starting with the area code?

( ) -

1) Daytime or

2) Evening/weekend

Thank you very much for taking the time to complete this interview.

Mental Health and Social Services School Questionnaire—Public Use Version 0