Parent/Guardian Survey 

The Lawrence County Health Department and Lawrence County School Districts are thinking about opening a School‐Based Health Center. Children attending schools within Lawrence County would be eligible to receive services at the School‐Based Health Center. Services might include immunizations, physical exams, care of minor illnesses (earaches, sore throats, cuts and bruises) and related family support services. The cost of services would be based on a sliding‐fee scale, and no one would be refused service because of inability to pay.
 
To help us plan for the School‐Based Health Center, we would like to ask a few questions about the health needs of your child. This information will help us decide what types of services and programs to offer at the Center. Your answers are completely confidential. You do not need to put your name anywhere on this form.
Thank you for your help.

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* What physical health problems or needs has your child experienced in the past month? Check all that apply.

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* Have you been told by a doctor that your child has any of the following   chronic health problems?

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* Where do you regularly take your child for health care? Check all that apply.

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* Do you have a regular source of dental care for your child?

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* Do you have someone you could go to for counseling services for behavioral problems? (e.g., unusual or extreme fears, depression, nervousness)

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* How do you currently pay for health services?

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* If we opened a School Based Health Center, how likely would you be to take your child there for service?  Check one.

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* At what hours would you be most likely to use the clinic? 
Check all that apply.

 

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* If you were unable to attend the appointment with your child, would you be willing to use Telehealth to participate in your child’s visit?

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* What school does your child/children attend? Check all that apply.

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