Behavioral Health Survey Evaluation
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1.
First Name
(Required.)
2.
Last Name (Optional)
*
3.
Email Address
(Required.)
*
4.
Name of School Child Attends
(Required.)
*
5.
What grade is your child currently in?
(Required.)
6th
9th
Other (please specify)
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6.
What is your relationship to your child (Please circle response)?
(Required.)
Mother
Father
Step-Mother
Step-Father
Guardian
Other (please specify)
7.
Number of children
1
2
3
4
5
more than 5
I Prefer Not To Answer
8.
Age of children (please select all that apply)
under 5
5-10
11-14
15-17
18+
I Prefer Not To Answer
*
9.
Ethnicity
(Required.)
African American/Black
Asian American
Hispanic/Latino
Native American
Pacific Islander
White/Caucasian
I Prefer Not To Answer
Another Ethnicity or Multiple Ethnicities (please specify)
*
10.
Where did you receive this Toolkit?
(Required.)
School
Pediatrician
Mental Health Professional
Community Center
Friend
Other (please specify)
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11.
What county do you live in?
(Required.)
Atlantic
Bergen
Burlington
Camden
Cape May
Cumberland
Essex
Glouchester
Hudson
Hunterdon
Mercer
Middlesex
Monmouth
Morris
Ocean
Passaic
Salem
Somerset
Sussex
Union
Warren
I live outside of New Jersey
12.
The zip code I live in is:
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13.
I found this Toolkit to be helpful as a parent/caregiver.
(Required.)
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
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14.
This Toolkit helped me be more comfortable in speaking to my kids about behavioral/mental health.
(Required.)
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
*
15.
This Toolkit helped increase my knowledge about behavioral/mental health.
(Required.)
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
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16.
This Toolkit helped explain when I may need to be concerned about my child.
(Required.)
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
*
17.
This Toolkit provides resources available to support my child's behavioral/mental health.
(Required.)
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
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18.
How likely are you to recommend this Toolkit to others?
(Required.)
Very likely
Likely
Neither likely nor unlikely
Unlikely
Very unlikely
19.
Please provide any additional comments or feedback regarding the presentation.
Current Progress,
0 of 19 answered