SBHC Parent/Caregiver

Mission:

The purpose of this survey is for Community Health Care to learn more about your students health concerns as we develop a School-Based Health Center. A School-Based Health Center provides health services to students with convenient and compassionate care without removing the child from school. Families interested in enrolling into the SBHC will be eligible to receive all services provided at the request of the parent/caregiver or under the advisement of CHC's medical team. Please fill out this survey so we can understand more about your student.

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* 1. What is the name of your school?

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* 2. Has your child ever had to miss school due to a health-related event or appointment?

Yes

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* 3. Do you often have to miss work due to a health-related event (illness, chronic pain, appointment, etc.) concerning your child?

Yes

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* 4. What challenges have you faced in accessing healthcare? Please check all that apply.

Finding a provider

Transportation

Health Insurance

Affordability (insurance co-pays, medications, deductibles, etc.)

Distrust of healthcare system

Religious beliefs

Accessibility

Language barriers (lack of translation services)

Health literacy/transparency (understanding my own health information)

Unaware of specific services that meet my family's needs

Other (please specify)

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* 5. Is your family covered under a health insurance plan?

Yes

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* 6. Please check all the health services your child/family could most benefit from.

Primary Care (Physicals, Immunizations/Vaccinations)

Mental/Behavioral Health (ADHD, Depression, Anxiety, Bipolar, etc.)

Dental Services (Screening, Treatment, Maintenance)

Reproductive Health/Education (Birth Control, OB/GYN, STD/STI testing)

Chronic Conditions (Diabetes, Asthma, etc.)

Other (please specify)

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* 7. Would your family be interested in learning more about Community Health Care's School Based Healthcare Program coming to your child's school?

Yes

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* 8. Can Community Health Care contact you regarding information about our School Based Healthcare program and how your family can enroll?

Yes

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* 9. What is the name of your student? (This information will not be shared with anyone other than Community Health Care project manager.) (Optional)

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* 10. Please fill in your contact information. (Optional)

Name

School

Email Address

Phone Number