National Association of State Directors of Special Education
UCLA School Mental Health Project
UMB Center for Mental Health Assistance
Public reporting burden for this collection of information is estimated to average 60 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. Send comments regarding this burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden to SAMHSA Reports Clearance Officer, Paperwork Reduction Project (0930-0241), Room 16-105, Parklawn Building, 5600 Fishers Lane, Rockville, MD 20857. 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 0930-0241.
Definitions
The focus of this survey is on mental health interventions for students in your school.
Mental health interventions are defined as:
Those mental health services and supports delivered to individual students who have been referred and identified as having psychosocial or mental health problems.
When answering questions about these mental health services include:
Mental health services for all students, both special education and general education students;
All mental health services supported by your district or school, both those provided directly by the school or district and those provided by community-based organizations with which your school or district has a contractual or formal agreement;
Mental health services delivered in district/school settings and in community settings if provided through contract or formal agreements;
Mental health services delivered by mental health staff whether they are school-based, district-based, or community-based if provided by organizations or providers with which the school or district has a formal agreement for services.
We realize that many schools also have preventive mental health programs for the broader student body. You will have an opportunity to tell us about those programs in item 28. For the purpose of that item please use the following definition:
Preventive mental health programs are those programs, activities and curricula provided to the general student population for the purpose of preventing social, emotional and adjustment problems.
Instructions
Please use a pencil to complete this survey.
All questions refer to the current school year, unless otherwise specified.
Answer these questions only for the school identified on the address label.
If you have any questions about this questionnaire, please contact Dennese Neal, Assistant Survey Director at the toll-free number 1-866-373-1024.
RETURN YOUR COMPLETED QUESTIONNAIRE IN THE ENVELOPE PROVIDED TO:
ABT ASSOCIATES INC.
Attn: Survey of School Mental Health Services
55 Wheeler St
Cambridge, MA 02138-9972
Basic School Characteristics
Before we ask you questions specifically about mental health services in your school, we would like some information about basic characteristics of your school. You may have to ask someone in the school office for some of this information.
On or about the first of October of this school year, what was the total enrollment in your school?
students
For the current school year (2002-2003), please check the box for each grade offered at your school.
Pre-kindergarten
Kindergarten
1 st
2 nd
3 rd
4 th
5 th
6 th
7 th
8 th
9 th
10 th
11 th
12 th
Of the total number of students enrolled in your school as reported in item 1, how many are:
Of the total number of students enrolled in your school as reported in item 1, how many are:
Students identified as limited English proficient or English language-learners .......................
________
Students with an Individualized Education Program (IEP) as defined by the Individuals with Disabilities Education Act (IDEA) .....................................
________
Students eligible for free or reduced-price lunch ....................
________
Delivery of Mental Health Services
The next questions ask about delivery of mental health services in your school and relationships with the school district.
Mental health services are defined as:
o Those services and supports delivered to individual students who have been referred and identified as having psychosocial or mental health problems.
5. Which students may receive these mental health services?
a. All students
b. Special education students only
6. How are mental health services managed in your school?
(Check all that apply)
a. One person or team manages mental health services for all students (both general education and special education).
b. One person or team manages mental health services for special education students only.
c. One person or team manages mental health services for general education students only.
d. No one manages mental health services at this school.
e. Other ____________________________________________________________
(please describe)
7. Does your district operate a mental health unit or clinic?
Yes
No [SKIP to Item 9].
8. Where is this MH unit or clinic located?
In this school
Outside this school
9. Does your school worh with community agencies to provide mental health services for students in your school?
Yes
No
Who has responsibility for each of the following functions for mental health services provided to GENERAL EDUCATION students in your school?
Check all that apply
NA
School
District
Collaborative/
Intermediate
Unit
Allocating funds for MH services ................
Establishing policies, guidelines or standards on MH service delivery ...............................
Determining the number and types of MH staff needed in your school ..........................
Hiring mental health staff ............................
Planning in-service training and professional development for MH staff ..........................
Administering contracts or agreements with outside organizations or agencies providing MH services .........................................
Mental Health Staff in School
The next questions ask about the types of staff providing mental health services to students enrolled in your school.
12. How are MH services staffed in your school?
(Check all that apply)
Mental health staff are school-based. (i.e. employees of the district or school who are assigned to this school and work only in this school).
Mental health staff are district-based. (i.e. employees of the district who are assigned to the district and travel to different schools, spending only part of their time in this school).
A collaborative or intermediate unit provides the MH staff.
A community provider or organization provides the MH staff.
Other (please describe) ________________________________________________
13. On average, circle how frequently your school staff uses the following strategies to coordinate activities and services for students in your school.
(1)
(2)
(3)
(4)
Interdisciplinary team meetings among MH staff
Weekly
Monthly
Quarterly
Rarely
or never
Joint planning sessions between MH staff and regular classroom teachers
Weekly
Monthly
Quarterly
Rarely
or never
Joint planning sessions between MH staff and special education teachers
Weekly
Monthly
Quarterly
Rarely
or never
Professional development on MH topics for regular school staff
Weekly
Monthly
Quarterly
Rarely
or never
Sharing of MH resources among school staff (e.g. printed materials, videos, exchange of referral info.)
Weekly
Monthly
Quarterly
Rarely
or never
Informal communication about MH issues or services (phone, e-mail) among school staff
Weekly
Monthly
Quarterly
Rarely
or never
14. How many of the following staff provide mental health services to students in your school? Include both school-based and district-based staff.
In column 1 indicate the total number for each type of staff that your school has. Put in ‘0’ for none. Of the total, i ndicate the number who are fulltime (column 2) or part-time (column 3). In column 4 indicate the percent of time (on average) each type of staff spends providing mental health services to students.
(1)
(2)
(3)
(4)
School Staff
Numberof positions
Number
fulltime
Number
part-time
Percent
Time
School counselor .........................................
____
____
____
________%
Mental health counselor ..............................
____
____
____
________%
School social worker ....................................
____
____
____
________%
School psychologist ....................................
____
____
____
________%
Ph.D-level clinical psychologist or counseling psychologist ................................................
____
____
____
________%
Alcohol/substance abuse counselor .............
____
____
____
________%
School nurse ...............................................
15. Of the total staff in each category reported in column 1 of item 14, indicate in column 1 the number with a master’s degree or higher in their field. In column 2 indicate the number with licensure or certification in their field.
(1)
(2)
School Staff
Number with
Master’s degree or higher in their field
Number with
license or certificate in their field
School counselor .............................
____
____
Mental health counselor ...................
____
____
School social worker ........................
____
____
School psychologist ..........................
____
____
Ph.D-level clinical psychologist or counseling psychologist ....................
Arrangements with Community Organizations and Individual Providers
16. Does your school or district have formal or contractual agreements with any community-based organizations or individual providers to provide mental health services to students enrolled in your school?
Yes
No [Skip to item 18]
17. For each of the following community-based organizations or individual providers, indicate in column 1 whether or not your school has an agreement, in column 2 where the service is provided, and column 3 who pays for the service.
(1)
(2)
(3)
If YES,
where provided
(Check one or both)
If YES, paid by
(Check all that apply)
YES
N
O
In school
In
community
School or district
Community
(e.g. agency or county)
3rd party payment
(Medicaid, private)
Grant
funds
Community-based Organizations
School-based health center operated by a community-based organization ................................ .................................................
Community health center or clinic (public or private) ......................
County or community mental health agency or center ................
Local hospital .............................
Child welfare agency ...................
Juvenile justice system or court ....
Faith-based organizations .............
Community service organization
(e.g. YMCA, Boys & Girls Club) ..
Other, describe ___________________________
Individual Providers
Psychologist, psychiatrist, social worker, or mental health counselor. ..................................
18. What are your general practices for routine referrals to and coordination with community-based organizations or providers?
Staff make p assive referrals (e.g. give brochures, lists, phone numbers of providers)
Staff make a ctive referrals (e.g. staff complete form with family, make calls or appointments, assist with transportation.)
Staff f ollow-up with student/family (e.g. calls to ensure appointment kept, assess satisfaction with referral, need for follow-up)
Staff f ollow-up with provider (via phone, e-mail, mail)
Staff a ttend team meetings with staff of community providers
Psychosocial or Mental Health Problems The next questions ask about the types of psychosocial or mental health problems that are seen in your school.
19. Using the code list below, rank the 3 most frequent problems for each group:
(Use the letter codes a. to n. to indicate the problem.)
Female students
Male students
1 st ________
1 st ________
2 nd ________
2 nd ________
3 rd ________
3 rd ________
20. Overall, which problem uses most of your school’s mental health resources (e.g. staff time, materials)?
( Use letter code to indicate the problem.)
_________
Code list of psychosocial or mental health problems for questions 19 and 20.
Use the letter code to indicate the problem.
Adjustment issues (e.g. difficulty managing transition to new school, new grade or class)
Social, interpersonal or family problems
Anxiety, stress, school phobia
Depression, grief reactions
Aggressive/disruptive behavior, bullying
Behavior problems associated with neurological disorders (e.g., attention deficit disorder with or without hyperactivity, epilepsy, Tourette’s syndrome)
Delinquency and gang-related problems
Suicidal or homicidal thoughts or behavior
Alcohol/drug problems
Eating disorders
Concerns about gender or sexuality
Experience of physical or sexual abuse
Sexual aggression, including harassment
Major psychiatric or developmental disorders (e.g., psychosis, bipolar disorder, Autism)
Mental Health Services Provided to Students in your School
21. Does your school provide the following services, either directly or through a community based organization with which you have a formal arrangement? If YES, also indicate who provides the service.
If YES, check all that apply
YES
NO
Provided by
school or
district staff
Provided by community
staff
Assessment for emotional or behavioral problems or disorders (including behavioral observation, psychosocial assessment, and psychological testing) ...........................................................
Case management (monitoring and coordination of services) ............................................................
Referral to specialized programs or services for emotional or behavioral problems or disorders (e.g. eating disorders) .........................................
Medication for emotional or behavioral problems ..
Referral for medication management ...................
Family support services (e.g. child/family advocacy, counseling) .........................................
22. How many students in your school received one or more of the above mental health services during the last school year (2001-2002)?
_________ (number) OR _________ (%)
23. Using the following scale from 1 to 4 where “1” is “not difficult” and 4 is “very difficult”, circle the degree of difficulty that your school has in providing the following mental health services for your students.Check NA if service is not available in your school.
Not — > — > — > — > Very
difficult difficult
NA
Assessment for emotional or behavioral problems or disorders (including behavioral observation, psychosocial assessment, and psychological testing) ..............
Case management (monitoring, coordination of services)
1 2 3 4
Referral to specialized programs or services for emotional or behavioral problems or disorders (e.g. eating disorders) ...............................................................
Medication for emotional or behavioral problems ......
1 2 3 4
Referral for medication management .......................
1 2 3 4
Family support services (child/family advocacy, counseling) .............................................................
1 2 3 4
24. Using the following scale from 1 to 4 where “1” is “not a barrier” and “4” is a “ serious barrier”, circle the extent to which each of the following is a barrier in delivering mental health services to your students.
Not a — > — > — > Serious
barrier barrier
School mental health resources are inadequate to meet student needs (e.g. waiting lists, limited space or staff availability) .............................................................
1 2 3 4
Competing priorities take precedence over mental health services ...............................................................
If more than one person was involved in completing this survey, please indicate who.
Principal
Assistant Principal
Director of Mental Health Services (or Student Support Services)
School secretary _____________________________________
School counselor, school psychologist, school social worker or other mental health staff
Other (Please provide title)__________________________________________________
If you have any comments you would like to make about this survey or about funding mental health services, please use the space below.
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
Thank you very much for completing this survey!
RETURN COMPLETED QUESTIONNAIRE IN THE ENVELOPE PROVIDEDTO:
ABT ASSOCIATES INC.
Attn: Survey of School Mental Health Services
55 Wheeler St.
Cambridge, MA 02138-9972
