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Children's Behavioral Health Committee - Best Practices Survey

Agency/Provider Name
Name of Person Completing Questionnaire
Email Address/Phone Number of Provider
Please select the region/area provider represents.
Please provide the name of the location (city, county, municipality, township, etc).
Evidence-Based Best Practices

Please list 1-3 evidence-based best practices that you currently use and check the list of items describing those practices.
Evidence-Based Best Practices #1
1a. Identify the youth serving system for Best Practice #I.
1b. Select the clinical types provided for Best Practice #I. Please select all that apply.
1c. Identify the setting for Best Practice # I.
1d. Identify the geographic area served for Best Practice # I.
1e. Identify the age group the program targets for Best Practice #I.
1f. Total Program Cost for Best Practice #I.
Evidence-Based Best Practices #2
2a. Identify the youth serving system for Best Practices #2.
2b. Select the clinical types provided for Best Practices #2. Please select all that apply.
2c. Identify the setting for Best Practices #2.
2d. Identify the geographic area served for Best Practices #2.
2e. Identify the age group served for Best Practices #2.
2f. Total Program Cost for Best Practices #2.
Evidence-Based Best Practices #3
3a. Identify the youth serving system for Best Practice #3.
3b. Select the clinical types provided for Best Practice #3. Please select all that apply.
3c. Identify the setting for Best Practice #3.
3d. Identify the geographic area served for Best Practices #3.
3e. Identify the age group for Best Practices #3.
3f. Total Program Cost for Best Practices #3.
Community-Support Best Practices

Please identify 1-3 community-support best practices that you currently use and check the list of items describing those practices.
Community Support Best Practices #1
1a. Identify the community setting for Best Practice #1.
1b. Identify the geographic area served for Community Support Best Practices #1.
1c. Total Program Cost for Community Support Best Practices #1.
Community Support Best Practices #2
2a. Identify the community setting for Best Practice #2.
2b. Identify the geographic area served for Community Support Best Practices #2.
2c. Total Program Cost for Community Support Best Practices #2.
Community Support Best Practices #3
3a. Identify the community setting for Best Practice #3.
3b. Identify the geographic area served for Community Support Best Practices #3.
3c. Total Program Cost for Community Support Best Practices #3.
Please use space below for further explanation.