Exit How can we help you and your family? Community Parent Questionnaire Question Title * 1. Are you the parent or guardian of a child or adolescent? Yes No I'm a mentor or family member Other (please specify) Question Title * 2. What is the age range(s) of your child? Select all that apply 5-7 8-10 11-13 14-16 17-21 Question Title * 3. Are you able to support and assist your child during virtual school? Not really A little Moderately Often Most times Question Title * 4. How has your child adapted to virtual learning? Question Title * 5. Does your child have social groups of friends in the school and community? How have they maintained their friendships while practicing safety precautions due to COVID? Question Title * 6. Would your child benefit from a bi-weekly group session via zoom to improve self awareness, self esteem, and self expression through reading and performing arts? Yes No Question Title * 7. Would your child benefit from a bi-weekly group session via zoom to discuss identity, emotional intelligence, self love, and good decision making skills with peers and a Qualified Mental Health Professional? Yes No Question Title * 8. Could you benefit from parental supports, resources, and guidance? For example: resource list for therapists, tutoring, performing arts outlets, parenting support groups, etc. Yes No Question Title * 9. Are you interested and/or open for you and your child(ren) to receive therapy via telehealth on a monthly basis? Yes No Question Title * 10. Is your child displaying negative or inappropriate behaviors in the home and community? Please identify the negative behaviors by selecting all that apply: Noncompliance with household rules Disrespecting Authority Sibling Rivalry Ineffective Communication Anger Outbursts Tantrums Lack of Focus Self Harming Suicidal Ideation Poor decision making skills Peer pressure Bullying Lack of boundaries Unhealthy relationships Safety Concerns Risky Behavior Sexual behavior Unsatisfactory academic progress Other (please specify) Done