MO.gov
DMH - Youth Consumer Survey
Please help our agency make services better by answering some questions about the services your child received OVER THE PAST YEAR.
Your answers are confidential and will not influence the services you or your child receive.
Which agency does your child receive services from?
*
Please select
Arthur Center
BJC (Farmington)
BJC (St. Louis)
BJC (St. Louis County)
Bootheel
Burrell (Columbia)
Burrell (Springfield)
Clark Center
Community Counseling Center (Bollinger)
Community Counseling Center (Cape Girardeau)
Community Counseling Center (Madison)
Community Counseling Center (Perry)
Community Counseling Center (Sainte Genevieve)
Compass (Jefferson County)
Compass (Clinton)
Compass (Jefferson City)
Compass (Rolla)
Compass (Warrensburg)
Compass (Wentzville)
Comprehensive Mental Health Services
Family Counseling
Family Guidance Center
Hopewell Center
Mark Twain
North Central
Ozark Center
Ozarks Healthcare
Places for People
Preferred Family (Hannibal)
Preferred Family (Kirksville)
Preferred Family (Trenton)
ReDiscover
Swope
Tri-County
Truman
Instructions: Fill in the circle that best represents your opinion (agreement or disagreement) of each item.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
1. Overall, I am satisfied with the services my child received.
1
2
3
4
5
2. I helped to choose my child's services.
1
2
3
4
5
3. I helped to choose my child's treatment goals.
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2
3
4
5
4. The people helping my child stuck with us no matter what.
1
2
3
4
5
5. I felt my child had someone to talk to when he/she was troubled.
1
2
3
4
5
6. I participated in my child's treatment.
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3
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5
7. The services my child and/or family received were right for us.
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3
4
5
8. The location of services was convenient for us.
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5
9. Services were available at times that were convenient for us.
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5
10. My family got the help we wanted for my child.
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5
11. My family got as much help as we needed for my child.
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3
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5
12. Staff treated me with respect.
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5
13. Staff respected my family's religious/spiritual beliefs.
1
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5
14. Staff spoke with me in a way that I understand.
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3
4
5
15. Staff were sensitive to my cultural/ethnic background.
1
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3
4
5
16. My child is better at handling daily life.
1
2
3
4
5
17. My child gets along better with family members.
1
2
3
4
5
18. My child gets along with friends and other people.
1
2
3
4
5
19. My child is doing better in school and/or work.
1
2
3
4
5
20. My child is better able to cope when things go wrong.
1
2
3
4
5
21. I am satisfied with our family life right now.
1
2
3
4
5
22. My child is better able to do things he or she wants to do.
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5
23. I know people who will listen and understand me when I need to talk.
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5
24. I have people that I am comfortable talking with about my child's problems.
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5
25. In a crisis, I would have the support I need from family or friends.
1
2
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4
5
26. I have people with whom I can do enjoyable things.
1
2
3
4
5
Please answer the following questions to let us know how your child is doing.
What programs are your child involved in? (mark all that apply)
Community Psychiatric Rehabilitation
Other Mental Health Programs
Comprehensive Substance Treatment and Rehabilitation
Other Substance Use Treatment Programs
How long has your child been enrolled in programs?
Less than one year
One year or more
27. Is your child currently living with you? (mark all that apply)
Yes
No
28. Has your child lived in any of the following places in the last year? (Check all that apply)
With one or both parents
Therapeutic foster home
Group home
Local jail or detention cetner
With another family member
Crisis shelter
Residential treatment center
State correctional facility
Runaway/Homeless/On the Streets
Foster home
Homeless shelter
Hospital
Other
29. In the last year, did your child see a medical doctor (or nurse) for a health check up or because he/she was sick?
Yes, in a clinic or office
Yes, but only in a hospital emergency room
No
Do not remember
30. Is your child on medication for emotional/behavioral problems?
Yes
No
30a. If yes, did the doctor or nurse tell you/or your child what side effects to watch for?
Yes
No
31. Is your child still getting services from this center?
Yes
No
32. Was your child arrested during the last 12 months?
Yes
No
33. Was your child arrested during the 12 months prior to that?
Yes
No
34. Over the last year, have your child's encounters with the police...
Been reduced
Stayed the same
Increased
Not applicable
35. Was your child expelled or suspended during the last 12 months?
Yes
No
36. Was your child expelled or suspended during the 12 months prior to that?
Yes
No
37. Over the last year, the number of days my child was in school is?
Greater
About the same
Less
Does not apply (please select why)
37a. Does not apply (please select why)
no problem with attendance before starting services
child is too young to be in school
child was expelled from school
child is home schooled
child dropped out of school
Other
38. Are either of the child's parents Hispanic/Latino?
Hispanic or Latino
Not Hispanic or Latino
39. What is your child's race? (mark all that apply)
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific Islander
White (Caucasian)
Black (African American)
Other
40. What is your child's age? (in years)
0-3
13-17
4-12
18+
41. Child's Gender:
Male
Female
Male and Female
Male from Female
Female from Male
Agender
Non-binary
Gender fluid
Genderqueer/Gender Nonconforming
Intersex
Not Specified
Not Known
42. Does your child have medical insurance?
Yes
No
Do Not Fill This Out
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