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  2. 2017
  3. June
  4. O
  5. One Month Follow-UP
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Exit Survey
 
Please provide your contact information. Only include phone number and email address if they have changed since discharge. 
First Name : 
Last Name : 
Phone : 
Email Address : 
 
 
Please rate the degree to which your child has experienced the following problems in the past 30 days. 
Not at All Once or Twice Several Times Often Most of the Time All of the Time
Arguing with others
Getting into fights
Yelling, swearing or screaming at others
Fits of anger
Refusing to do things
 
 
Please rate the degree to which your child has experienced the following problems in the past 30 days. 
Not at All Once or Twice Several Times Often Most of the Time All of the Time
Causing trouble for no reason
Using drugs or alcohol
Breaking rules or breaking the law (out past curfew, stealing)
Skipping school or classes
Lying
 
 
Please rate the degree to which your child has experienced the following problems in the past 30 days. 
Not at All Once or Twice Several Times Often Most of the Time All of the Time
Can't seem to sit still, having too much energy
Hurting self (cutting or scratching self, taking pills)
Talking or thinking about death
Feeling worthless or useless
Feeling lonely and having no friends
 
 
Please rate the degree to which your child has experienced the following problems in the past 30 days. 
Not at All Once or Twice Several Times Often Most of the Time All of the Time
Feeling anxious or fearful
Worrying that something bad is going to happen
Feeling sad or depressed
Nightmares
Eating problems
 
 
 
Overall, How satisfied are you with your relationship to your child right now? 
 
Extremely Satisfied
 
Moderately Satisfied
 
Somewhat Satisfied
 
Somewhat Dissatisfied
 
Moderately Dissatisfied
 
Extremely Dissatisfied
 
 
 
How capable of dealing with your child's problems do you feel right now? 
 
Extremely Capable
 
Moderately Capable
 
Somewhat CapableOption 3
 
Somewhat Incapable
 
Moderately Incapable
 
Extremely Incapable
 
 
 
How much stress or pressure is in your life right now? 
 
Very little
 
Some
 
Quite a bit
 
A moderate amount
 
A great deal
 
Unbearable amounts
 
 
 
How optimistic are you about your child's future right now? 
 
The future looks very bright
 
The future looks somewhat bright
 
The future looks OK
 
The future looks both good and bad
 
The future looks bad
 
The future looks very bad
 
 
 
Has your child remained in the home for the past thirty days? This means your child has not been hospitalized got psychiatric reasons or been out of the home for more than ten days
 
Option 1
 
Option 2