District 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
District 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
District Questionnaire

Questions

MODULE 1

Provision of Services 1–6

Collaboration and Promotion 7–9

Evaluation 10

Staffing Characteristics 11–21

Professional Development 22–25

Services Provided at Other Sites 26–29

MODULE 2

Mental Health and Social Services Coordinator 30–39

THIS QUESTIONNAIRE WILL BE ADMINISTERED USING WEB-BASED INTERVIEW TECHNOLOGY. AS THE RESPONDENT TYPES RESPONSES TO THE QUESTIONS INTO THE 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 ADDITIONAL CLARIFICATION ON THE QUESTION OR THE SPECIFIC TERMINOLOGY USED. THIS TEXT WILL APPEAR ON-SCREEN UNDER THE MAIN QUESTION TEXT. THE PROGRAMMING SPECIFICATIONS FOR THE INTERVIEW ARE NOT INCLUDED IN THIS PRINTED VERSION OF THE QUESTIONNAIRE.

1. This questionnaire focuses on your district’s policies and practices regarding mental health and social services.

2. For the purposes of this questionnaire, “policy” means any law, rule, regulation, administrative order, or similar kind of mandate issued by the local school board or other local agency with authority over schools in your district. SHPPS is most interested in what is required by the district, not what is recommended or contained in non-binding guidance documents, unless the question specifically asks about recommendations.

3. For the purposes of this questionnaire, “adopted a policy” means either that the district has its own policy or that the district follows a policy established at the state level, including any law, rule, regulation, administrative order, or similar kind of mandate.

4. If a district policy is worded in such a way that it requires schools to develop and adopt their own policies on a given topic, for the purposes of this questionnaire please consider it the same as a district-wide requirement.

5. District may sometimes grant policy exceptions or waivers, but please answer each question based on what is considered the general policy and standard practice in your district.

6. Please do not consider school practices or policies when answering the questions. This information is gathered during data collection from schools across the country.

7. For the purposes of this questionnaire, “elementary school” refers to a school that contains any of grades K–5. “Middle school” refers to a school that contains any of grades 6–8. Some jurisdictions may refer to these schools as “junior high schools.” “High school” refers to a school that contains any of grades 10–12. Some jurisdictions may refer to these schools as “senior high schools.”

The following questions ask about standard mental health and social services, such as crisis intervention, identification of emotional disorders, or assistance with enrolling in Medicaid, offered to all students at a school. These services usually are provided by a school counselor, psychologist, or social worker but also could be provided at the school by staff from collaborating community agencies.

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

1. Has your district adopted a policy stating that student assistance programs will be offered to all students?

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.

2. Has your district adopted a policy stating that schools will create and maintain such teams?

Yes 1

No 2

3. Has your district adopted a policy stating that school mental health or social services staff, for example school counselors, psychologists, or social workers will participate in the development of Individualized Education Programs (IEPs), when indicated?

Yes 1

No 2

4. Has your district adopted a policy stating that school mental health or social services staff will participate in the development of Individualized Health Plans (IHPs), when indicated?

Yes 1

No 2

5. Has your district adopted a policy stating that mental health or social services staff will participate in the development of 504 plans, when indicated?

Yes 1

No 2

6. In your district, 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

The next questions ask about collaboration and promotion on mental health and social services activities with other district-level staff and outside organizations.

7. During the past 12 months, have district-level mental health or social services staff worked on school mental health or social services activities with district-level…

No district-
level staff
Yes No in this area

1. Health education staff? 1 2 3

2. Physical education staff? 1 2 3

3. Nutrition or food service staff? 1 2 3

4. Health services staff? 1 2 3

5. School-based health center staff? 1 2 3

8. During the past 12 months, have district mental health or social services staff worked on school mental health or social services activities 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

9. During the past 12 months, has anyone from your district provided families of all students with information on school mental health or social services?

Yes 1

No 2

The next questions ask about different aspects of your district’s mental health or social services program that might have been evaluated during the past two years.

10. During the past two years, has your district evaluated…

Yes No

1. School mental health or social services programs? 1 2

2. School mental health or social services policies? 1 2

3. Mental health or social services professional development
   or in-service programs? 1 2

4. Student use of school mental health or social services? 1 2

5. Student or family satisfaction with school mental health
   or social services? 1 2

The next questions ask about the minimum level of education required for mental health and social services staff in your district.

11. Based on policies adopted by your district, 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

Specific education requirements are not
described 4

12. Has your district adopted a policy stating that a newly hired school counselor will 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

13. Based on policies adopted by your district, 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

Doctoral degree in psychology 3

Other degree (Specify) 4

Specific education requirements are not
described 5

14. Has your district adopted a policy stating that a newly hired school psychologist will 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

15. Based on policies adopted by your district, 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

Specific education requirements are not
described 4

16. Has your district adopted a policy stating that a newly hired school social worker will 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. Has your district adopted a policy stating that school mental health or social services staff are required to earn continuing education credits on mental health or social services topics?

Yes 1

No 2

The next questions ask about your district’s policies regarding mental health and social services staffing at schools in your district.

ANSWER Q18 IF DISTRICT CONTAINS ELEMENTARY SCHOOLS. OTHERWISE, SKIP TO THE INSTRUCTIONS BEFORE Q19.

18. Has your district adopted a policy stating that each elementary school will have a specified ratio of counselors to students?

Yes 1

No 2

ANSWER Q19 IF DISTRICT CONTAINS MIDDLE SCHOOLS. OTHERWISE, SKIP TO THE INSTRUCTIONS BEFORE Q20.

19. Has your district adopted a policy stating that each middle school will have a specified ratio of counselors to students?

Yes 1

No 2

ANSWER Q20 IF DISTRICT CONTAINS HIGH SCHOOLS. OTHERWISE, SKIP TO THE INSTRUCTIONS BEFORE Q21.

20. Has your district adopted a policy stating that each high school will have a specified ratio of counselors to students?

Yes 1

No 2

21. Has your district adopted a policy stating that each school will have someone to oversee or coordinate mental health or social services at the school?

Yes 1

No 2

The next questions ask about professional development that might have been offered to mental health or social services staff during the past two years. This might include workshops, conferences, continuing education, graduate courses, or any other kind of in-service.

22. During the past two years, has your district provided funding for or offered professional development to mental health or social services staff 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

23. During the past two years, has your district provided funding for or offered professional development to mental health or social services staff 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

24. During the past two years, has your district provided funding for or offered professional development to mental health or social services staff 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

The next question asks about training for teachers, administrators, and school staff other than mental health and social services staff.

25. During the past two years, has your district provided funding for or offered training to any teachers, administrators, or other school staff on…

Yes No

1. Recognizing signs and symptoms of physical, sexual,
   or emotional abuse? 1 2

2. Recognizing signs and symptoms of substance abuse? 1 2

3. Recognizing signs and symptoms of depression and
   suicidality? 1 2

ASK Q25D IF DISTRICT CONTAINS MIDDLE SCHOOLS OR HIGH SCHOOLS. OTHERWISE, SKIP TO Q25E.

4. Recognizing signs and symptoms of dating violence? 1 2

5. Recognizing signs and symptoms of bullying
   victimization? 1 2

6. Making appropriate referrals to a school counselor,
   psychologist, or social worker? 1 2

7. Managing students with emotional or
   behavioral problems? 1 2

This next set of questions asks about mental health and social services delivered to students or families at other sites not on school property regardless of whether the services are paid for by the school system. These services might be provided by mental health and 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.

26. Currently, does your district have such arrangements to provide mental health or social services to students or families in your district?

Yes 1

No 2 SKIP TO Q30

The next question asks which mental health or social services organizations or professionals have arrangements with your district to provide mental health or social services to students or families.

27. Does your district have arrangements with…

Yes No

1. A school-linked health center? 1 2

2. A community health clinic or health center? 1 2

3. A local health department? 1 2

4. A local hospital? 1 2

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

6. A university, medical school, or nursing school? 1 2

7. A managed care organization? 1 2

8. A private psychologist? 1 2

9. A private psychiatrist? 1 2

10. A private social worker? 1 2

11. A private counselor? 1 2

28. Does your district have arrangements with any organizations or mental health or social services professionals to provide…

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. 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

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

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 with accessing benefits for students with
    disabilities? 1 2

29. Does your district have arrangements with mental health or social services organizations or 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

30. Currently, does someone in your district oversee or coordinate school mental health and social services?

Yes 1

No 2 That is the last question.
Thank you very much for taking the time to complete this questionnaire.

31. Are you this person?

Yes 1

No 2 That is the last question.
Thank you very much for taking the time to complete this questionnaire.

32. Do you work for the school district?

Yes 1

No 2

The last questions ask about your educational background.

33. Do you have an undergraduate degree?

Yes 1

No 2 That is the last question.
Thank you very much for taking the time to complete this questionnaire.

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

Counseling 1

Psychology 2

Social work 3

Education 4

Other (Specify) 5

35. Did you have an undergraduate minor?

Yes 1

No 2 SKIP TO Q37

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

Counseling 1

Psychology 2

Social work 3

Education 4

Other (Specify) 5

37. Do you have a graduate degree?

Yes 1

No 2 SKIP TO Q39

38. 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

39. Are you 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

Thank you very much for taking the time to participate in this study.

If you would like more information about this study or would like clarification of any questions in this questionnaire, please call 800-287-1815.

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