Families of Kids with Mood and Anxiety Disorders, Inc.: Structured Support Gatherings

1. Structured Support Gatherings in the Tampa Bay area

Families of Kids with Mood and Anxiety Disorders, Inc. appreciates your time and input on this survey. We hope to gain more information so that structured support gatherings may be planned.

The current format we are exploring is one where families and interested parties come together once a month. Caregivers would then go to an area and discussion/ideas can be shared. A mental health professional would be with the adults for discussion guidance. Younger children and teens would be in an area with age appropriate activities (think of crafts or games relating to feelings, for example).

1. Your information

Your information Your name
Phone number
Email address

2. Please indicate which of the following applies to you in your reason for filling out this survey.

Please indicate which of the following applies to you in your reason for filling out this survey. FAMILY MEMBER (please check which applies below)

Parent

Grandparent

Other family member

Teen with mood, anxiety or related disorder

CARE PROVIDER (please check which applies below)

Mental health counselor/social worker/therapist

Psychologist

Psychiatrist

Pediatrician/PCP

OTHER interested party in the community

If you chose "other interested party in the community," please specify.

3. Please list the age of your child or teen with a mood, anxiety or related disorder. Rows are provided for if you have more than one child or teen with a mood, anxiety or related disorder.
*IF YOU ARE A CARE PROVIDER filling this out in regards to your patients, please consider which patients would best benefit from meetings. Please respond with small ranges of ages (i.e., 7-8 years or 14-16 years)

Please list the age of your child or teen with a mood, anxiety or related disorder. Rows are provided for if you have more than one child or teen with a mood, anxiety or related disorder. *IF YOU ARE A CARE PROVIDER filling this out in regards to your patients, please consider which patients would best benefit from meetings. Please respond with small ranges of ages (i.e., 7-8 years or 14-16 years) 1:
2:
3:
4:

4. TYPES OF DISORDERS AND OTHER AREAS OF CONCERN: For each child or teen you listed in response to question 3 above, please check which of the following types of disorders apply (You may check more than one.). In the space provided below, you may indicate other areas of concern.
**IF YOU ARE A CARE PROVIDER, please check which apply to your patients.

	Depression	Bipolar Disorder	OCD	GAD	SAD	PTSD
Child/teen 1:	TYPES OF DISORDERS AND OTHER AREAS OF CONCERN: For each child or teen you listed in response to question 3 above, please check which of the following types of disorders apply (You may check more than one.). In the space provided below, you may indicate other areas of concern. **IF YOU ARE A CARE PROVIDER, please check which apply to your patients. Child/teen 1: Depression	Bipolar Disorder	OCD	GAD	SAD	PTSD
Child/teen 2:	Child/teen 2: Depression	Bipolar Disorder	OCD	GAD	SAD	PTSD
Child/teen 3:	Child/teen 3: Depression	Bipolar Disorder	OCD	GAD	SAD	PTSD
Child/teen 4:	Child/teen 4: Depression	Bipolar Disorder	OCD	GAD	SAD	PTSD

DISORDERS/SPECIAL NEEDS: In addition to those listed above, please specify any other mood, anxiety or related disorder/concern here (SLD, eating disorders, ADHD, etc.).

5. SPECIFIC AREAS OF INTEREST: Please indicate any specific areas of interest your family may have. Examples may be making and keeping friends, how to handle emotions, transitioning to college, GLBT questions, school bullying, etc.
**IF YOU ARE A CARE PROVIDER, please consider what applies to your patients.

SPECIFIC AREAS OF INTEREST: Please indicate any specific areas of interest your family may have. Examples may be making and keeping friends, how to handle emotions, transitioning to college, GLBT questions, school bullying, etc. **IF YOU ARE A CARE PROVIDER, please consider what applies to your patients.

6. SIBLINGS: Please list ages of any children or teens you have who do NOT have mood, anxiety or related disorders, as well as:
1) if your child/teen has no siblings (or, for example, if they have adult siblings who no longer live at home so their attendance is not an issue)
2) if you think they will NOT be attending meetings at all;
3) if you think they should be included in the regular meetings;
4) if you think they have a need for a special sibling meeting at the same time as regular meetings.

	No siblings	NOT attending	Included in regular meetings	Special sibling meetings
Sibling 1	SIBLINGS: Please list ages of any children or teens you have who do NOT have mood, anxiety or related disorders, as well as: 1) if your child/teen has no siblings (or, for example, if they have adult siblings who no longer live at home so their attendance is not an issue) 2) if you think they will NOT be attending meetings at all; 3) if you think they should be included in the regular meetings; 4) if you think they have a need for a special sibling meeting at the same time as regular meetings. Sibling 1 No siblings	NOT attending	Included in regular meetings	Special sibling meetings
Sibling 2	Sibling 2 No siblings	NOT attending	Included in regular meetings	Special sibling meetings
Sibling 3	Sibling 3 No siblings	NOT attending	Included in regular meetings	Special sibling meetings
Sibling 4	Sibling 4 No siblings	NOT attending	Included in regular meetings	Special sibling meetings

7. LOCATION: Which areas are BEST for you for meetings?

LOCATION: Which areas are BEST for you for meetings? South Tampa

Seminole Heights

New Tampa

Wesley Chapel

Carrollwood

Citrus Park

Brandon

Land O’Lakes

USF/Temple Terrace area

Other (please specify)

8. FREQUENCY OF MEETINGS: Would you like to meet once a month?

FREQUENCY OF MEETINGS: Would you like to meet once a month? Yes

If you chose "no," please indicate how often you would like to meet.

9. Which of the following would you be able to offer? Our goal is to main consistency while rotating volunteers so that no one has to volunteer more than once every 2-3 months (if not longer), unless they would like to. This especially applies to adult family members and caregivers as we want to ensure they have opportunity to take advantage of the support themselves.

	Providing meeting space	Volunteering in youth rooms (this selection is intended for parents, caregivers, grandparents, interested adults)	Volunteering to be in youth rooms (this selection is intended for health care professionals only - need not be in mental health field)	Volunteering to guide caregiver gatherings (this selection is intended for mental health care professionals only)
Adults not in health care (caregivers, parents, etc.)	Which of the following would you be able to offer? Our goal is to main consistency while rotating volunteers so that no one has to volunteer more than once every 2-3 months (if not longer), unless they would like to. This especially applies to adult family members and caregivers as we want to ensure they have opportunity to take advantage of the support themselves. Adults not in health care (caregivers, parents, etc.) Providing meeting space	Volunteering in youth rooms (this selection is intended for parents, caregivers, grandparents, interested adults)	Volunteering to be in youth rooms (this selection is intended for health care professionals only - need not be in mental health field)	Volunteering to guide caregiver gatherings (this selection is intended for mental health care professionals only)
Mental health care professionals	Mental health care professionals Providing meeting space	Volunteering in youth rooms (this selection is intended for parents, caregivers, grandparents, interested adults)	Volunteering to be in youth rooms (this selection is intended for health care professionals only - need not be in mental health field)	Volunteering to guide caregiver gatherings (this selection is intended for mental health care professionals only)
Other health care professionals	Other health care professionals Providing meeting space	Volunteering in youth rooms (this selection is intended for parents, caregivers, grandparents, interested adults)	Volunteering to be in youth rooms (this selection is intended for health care professionals only - need not be in mental health field)	Volunteering to guide caregiver gatherings (this selection is intended for mental health care professionals only)

10. If you have anything further to add that you feel would be helpful, please let us know.

If you have anything further to add that you feel would be helpful, please let us know.