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SECTION FS: CHILD VERSION - FINAL SERVICES MODULE

FS1. REVIEW SV28. DID RESPONDENT USE ANY SERVICE IN THE PAST 12 MONTHS?

YES 1

NO (GO TO FS7) 2

FS2. IF RESPONDENT USED ONLY ONE SERVICE, GO TO FS4. You said you have been seen by (FILL WITH LIST OF ALL POSITIVE RESPONSES IN COLUMN C FROM SERVICES SECTION). Of these, which has been the most helpful for your problems?

NAME: ______________________________

QUESTION NUMBER: ______

FS3. Which has helped the least?

NAME: ______________________________

QUESTION NUMBER: ______

FS4. Were there any other services, besides the ones you used, that you thought you needed?

YES 1

NO (GO TO SU1) 2

YES

NO

FS4a. Did you feel you needed school-based services?

1

2

FS4b. READ STEM IF NECESSARY: Did you feel you needed...

...hospital services?

1

2

FS4c. READ STEM IF NECESSARY: Did you feel you needed...

...out-patient services?

1

2

FS4d. READ STEM IF NECESSARY: Did you feel you needed...

...services through your church or temple?

1

2

FS4e. READ STEM IF NECESSARY: Did you feel you needed...

...juvenile justice services?

1

2

FS4f. READ STEM IF NECESSARY: Did you feel you needed...

...drug or alcohol treatment?

1

2

FS4g. READ STEM IF NECESSARY: Did you feel you needed...

...something else or perhaps something more specific?

Specify: _____________________________________

1

2

You said that you thought you needed additional services. Please tell me if any of these reasons kept you from getting that additional care in the past 12 months:

YES

NO

FS5a. You thought your problems were not so serious?

1

2

FS5b. READ STEM IF NECESSARY: Please tell me if any of these reasons kept you from getting that additional care in the past 12 months:

You decided you could handle your problems on your own?

1

2

FS5c. READ STEM IF NECESSARY: Please tell me if any of these reasons kept you from getting that additional care in the past 12 months:

Help cost too much money?

1

2

FS5d. READ STEM IF NECESSARY: Please tell me if any of these reasons kept you from getting that additional care in the past 12 months:

Services were too inconvenient to use?

1

2

FS5e. READ STEM IF NECESSARY: Please tell me if any of these reasons kept you from getting that additional care in the past 12 months:

The services were too far away?

1

2

FS5f. READ STEM IF NECESSARY: Please tell me if any of these reasons kept you from getting that additional care in the past 12 months:

You had a bad experience with the professionals?

1

2

FS5g. READ STEM IF NECESSARY: Please tell me if any of these reasons kept you from getting that additional care in the past 12 months:

You were afraid of what your family or friends would say?

1

2

FS5h. READ STEM IF NECESSARY: Please tell me if any of these reasons kept you from getting that additional care in the past 12 months:

You were afraid you would be taken away from your family?

1

2

FS5i. READ STEM IF NECESSARY: Please tell me if any of these reasons kept you from getting that additional care in the past 12 months:

You thought treatment would not help?

1

2

FS5j. READ STEM IF NECESSARY: Please tell me if any of these reasons kept you from getting that additional care in the past 12 months:

The people you trusted most did not recommend professional help?

1

2

FS5k. READ STEM IF NECESSARY: Please tell me if any of these reasons kept you from getting that additional care in the past 12 months:

You did not know who to trust for advice?

1

2

FS5l. READ STEM IF NECESSARY: Please tell me if any of these reasons kept you from getting that additional care in the past 12 months:

You didn’t know where to go?

1

2

FS5m. READ STEM IF NECESSARY: Please tell me if any of these reasons kept you from getting that additional care in the past 12 months:

You had no way to get there?

1

2

FS5n. READ STEM IF NECESSARY: Please tell me if any of these reasons kept you from getting that additional care in the past 12 months:

You had to wait a long time for an appointment?

1

2

FS5o. READ STEM IF NECESSARY: Please tell me if any of these reasons kept you from getting that additional care in the past 12 months:

You did not want to go?

1

2

FS5p. IF FS5o = 1 CONTINUE

OTHERS GO TO FS5q

Could you explain why you didn’t want to go. What made you feel that way?

SPECIFY: ______________________________________

1

2

FS5q. Was there any other reason that kept you from getting additional care in the past 12 months?

SPECIFY: ______________________________________

1

2

I’m going to read a statement. Tell me if it’s very true, somewhat true, or not at all true.

FS6. During the past year, you needed help for your problems with behaviors, emotions or feelings, drugs or alcohol, but you were not able to get that help.

Very true (GO TO SU1) 1

Somewhat true (GO TO SU1) 2

Not at all true (GO TO SU1) 3

FS7. You said you have not been admitted to a hospital, seen a professional, or received school services for behavioral, emotional, drug or alcohol or learning problems in the past 12 months. During the past 12 months, has there been a time when you thought you might need help for these problems?

YES 1

NO (GO TO SU1) 2

FS8. When was the first time you thought this in the past 12 months?

|___|___| |___|___|

MONTH YEAR

FS8a. When was the first time you thought this in the past 12 months?

YES 1

NO 2

FS8b. When was the last time you felt this way?

|___|___| |___|___|

MONTH YEAR

FS9. What were the most important reasons you thought you needed help?

TEXT #1: _________________________________________

TEXT #2: _________________________________________

TEXT #3: _________________________________________

|___|___|___|

|___|___|___|

|___|___|___|

What were the main reasons that you did not go to a hospital, a mental health specialist, or some other place or person outside the home for help?

YES

NO

FS10a. You thought your problems were not so serious?

1

2

FS10b. READ STEM IF NECESSARY: What were the main reasons that you did not go to a hospital, a mental health specialist, or some other place or person outside the home for help?

You decided you could handle your problems on your own?

1

2

FS10c. READ STEM IF NECESSARY: What were the main reasons that you did not go to a hospital, a mental health specialist, or some other place or person outside the home for help?

Help cost too much money?

1

2

FS10d. READ STEM IF NECESSARY: What were the main reasons that you did not go to a hospital, a mental health specialist, or some other place or person outside the home for help?

Services were too far away?

1

2

FS10e. READ STEM IF NECESSARY: What were the main reasons that you did not go to a hospital, a mental health specialist, or some other place or person outside the home for help?

The services were too far away?

1

2

FS10f. READ STEM IF NECESSARY: What were the main reasons that you did not go to a hospital, a mental health specialist, or some other place or person outside the home for help?

You had a bad experience with the professionals?

1

2

FS10g. READ STEM IF NECESSARY: What were the main reasons that you did not go to a hospital, a mental health specialist, or some other place or person outside the home for help?

You were afraid of what your family or friends would say?

1

2

FS10h. READ STEM IF NECESSARY: What were the main reasons that you did not go to a hospital, a mental health specialist, or some other place or person outside the home for help?

You were afraid you would be taken away from your family?

1

2

FS10i. READ STEM IF NECESSARY: What were the main reasons that you did not go to a hospital, a mental health specialist, or some other place or person outside the home for help?

You thought treatment would help?

1

2

FS10j. READ STEM IF NECESSARY: What were the main reasons that you did not go to a hospital, a mental health specialist, or some other place or person outside the home for help?

The people you trusted most did not recommend professional help?

1

2

FS10k. READ STEM IF NECESSARY: What were the main reasons that you did not go to a hospital, a mental health specialist, or some other place or person outside the home for help?

You did not know who to trust for advice?

1

2

FS10l. READ STEM IF NECESSARY: What were the main reasons that you did not go to a hospital, a mental health specialist, or some other place or person outside the home for help?

You didn’t know where to go?

1

2

FS10m. READ STEM IF NECESSARY: What were the main reasons that you did not go to a hospital, a mental health specialist, or some other place or person outside the home for help?

You had no way to get there?

1

2

FS10n. READ STEM IF NECESSARY: What were the main reasons that you did not go to a hospital, a mental health specialist, or some other place or person outside the home for help?

You had to wait a long time for an appointment?

1

2

FS10o. READ STEM IF NECESSARY: What were the main reasons that you did not go to a hospital, a mental health specialist, or some other place or person outside the home for help?

You did not want to go?

1

2

FS10p. IF FS10o = 1 CONTINUE

OTHERS GO TO FS10q

Could you explain why you didn’t want to go. What made you feel that way?

SPECIFY: ______________________________________

1

2

FS10q. Was there any other reason that kept you from getting additional care in the past 12 months?

SPECIFY: ______________________________________

1

2

I’m going to read a statement. Tell me if it is very true, somewhat true, or not at all true.

FS11. During the past year, you needed help for problems with behaviors, emotions or feelings, drugs or alcohol, but you were not able to get that help.

Very true 1

Somewhat true 2

Not at all true 3

 

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