Form Caregiver

Caregiver

Caregiver—Instruments

Attachment B: System of Care Assessment

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx

System/Program__________________________

Interviewer___________________

Site ID#_________________________________

Date________________________

Respondent Data Entry#____________________

Assessment #_________________

I. Caregiver of Child or Youth Served by the Program
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 90 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

To be conducted with the caregiver of a child or youth who has been served by the grant program in the
assessment period for at least 3 months but no longer than 12 months. Informants cannot include
therapeutic foster parents, caregivers who serve as program staff, or family representatives or advocates
responding on behalf of the selected caregiver respondent.

Introduction
Hello, my name is
. Thank you for taking time out of your busy day to help
us. Today I’ll be asking you questions about your family’s experience with the services
provided through (name of grant program) . That information will help us understand what works
best for children and families. Before we start, I want to make sure that you know that the
information you give me today will be kept private and will not be shared with the (name of
grant program) . In our report, everybody’s answers will be combined and the people who
gave us the information will not be identified. While answering these questions,
remember that you should concentrate on things that have happened since you came to
(name of grant program) .
[Note to interviewer: Review Consent form with respondent and obtain signature before
proceeding with the interview]
(NOTE TO INTERVIEWER: Question 1 skipped)

2.

Can you tell me why you become involved with (name of grant program) ? [Probe for reasons
the child or youth entered treatment.]
How did you learn about the (name of grant program) ? Who referred you?
How long has your child and family been receiving services through the program?

3.

What services do your child and family currently receive through (name of grant program)?

CMHI National Evaluation, Follow-up Assessment
Caregiver (I), February 2011
Phase VI

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4.

In addition to the services received through (name of grant program) , has your child and family
received services or treatments from any other providers, organizations, programs
or agencies? If yes, what were they?

Entry into Services
5.

When you first tried to get services, how complicated or difficult was it to get into
(E.7.b.)

(name of grant program) ?

Did you have to go through a lot of steps, fill out a lot of forms, talk to a lot of different
people, etc.?
Thinking back at all you had to do, rate on a scale of 1 to 5 (with 5 being the easiest),
how complicated or difficult it was to enter/enroll in (name of grant program) ?
Respondent’s rating
5=Entry process was not at all complicated/difficult. Very few
steps were involved.
4=Entry process was slightly complicated/difficult.
3=Entry process was somewhat complicated/difficult. Several
steps were involved.
2=Entry process was moderately complicated/difficult. Many steps
involved.
1=Entry process was extremely complicated/difficult. Very many
steps involved.

6.

Interviewer’s rating
5=Entry process was not at all complicated/difficult. Very few
steps were involved.
4=Entry process was slightly complicated/difficult.
3=Entry process was somewhat complicated/difficult. Several
steps were involved.
2=Entry process was moderately complicated/difficult. Many steps
involved.
1=Entry process was extremely complicated/difficult. Very many
steps involved.

How much time passed between when your child and family first tried to get into (name of
grant program) until you actually started receiving services through the program? Was
this a good timeframe for you, or did you need to receive services sooner? (E.7.c.)
On a scale of 1 to 5, with 5 being the best, how would you rate the length of time it took
for the your child or family’s first service to begin?

Respondent’s rating
5=Timeframe was perfect, no changes needed
4=Timeframe was very fast, could use minor improvement
3=Timeframe pretty fast, could use some improvement
2=Timeframe pretty slow, could use quite a bit of improvement
1=Timeframe entirely too slow, needs a great deal of improvement

7.

Interviewer’s rating
5=Timeframe was perfect, no changes needed
4=Timeframe was very fast, could use minor improvement
3=Timeframe pretty fast, could use some improvement
2=Timeframe pretty slow, could use quite a bit of improvement
1=Timeframe entirely too slow, needs a great deal of improvement

Did you feel that you and your family were treated with respect and made to feel
comfortable throughout the enrollment process? (E.1.a.)
Did you feel that the staff paid attention to and respected what you had to say?
On a scale from 1 to 5, with 5 being the best, how respected and comfortable did you
feel during the process for entering (name of grant program) ?

Respondent’s rating
5=Family felt extremely respected and comfortable
4=Family felt very respected and comfortable
3=Family felt moderately respected and comfortable
2=Family felt somewhat respected and comfortable
1=Family felt extremely disrespected and uncomfortable
CMHI National Evaluation, Follow-up Assessment
Caregiver (I), February 2011
Phase VI

Interviewer’s rating
5=Family felt extremely respected and comfortable
4=Family felt very respected and comfortable
3=Family felt moderately respected and comfortable
2=Family felt somewhat respected and comfortable
1=Family felt extremely disrespected and uncomfortable

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Service Planning
8.

Is there a main person at (name of grant program) who helps to decide what services your
child and family should receive? [Probe for the first name and function (e.g., case
manager/care coordinator or therapist) who works with the family to plan services.
Use that name where you see (name of case manager/therapist) ]

9.

Since entering (name of grant program) , has your child or family been involved with staff from
other agencies such as child welfare, juvenile justice, education, etc.? If yes, which
agencies? (F.5.a.)
If yes, did anyone from any of these agencies work with you and (name of case
plan services for your child and family? If so, who?

manager/therapist) to

Was there any other agency that you thought should have helped to plan services but
did not?
5=All involved agencies were present
4=Most involved agencies were present
3=Some involved agencies were present
2=Few of the involved agencies were present
1=One involved agency was present (but family involved with more than one)
666=Family involved with only one agency

10.

Considering all of the people who have worked with your child and family since
entering (name of grant program) , including the staff at (name of grant program) , the agencies you
just mentioned (if any), and other providers or organizations, how well do you think that
all of these different people worked with each other to plan services for your child
and family? (F.6.b.)
Do you think they could have done a better job working together so that the service
planning process would have been better coordinated?
On a scale from 1 to 5, with 5 being the best, how well do you think they all coordinated
the service planning process?

Respondent’s rating
5=Extremely coordinated
4=Very coordinated
3=Moderately coordinated
2=Somewhat coordinated
1=Not at all coordinated
666=Only one party involved

11.

Interviewer’s rating
5=Extremely coordinated
4=Very coordinated
3=Moderately coordinated
2=Somewhat coordinated
1=Not at all coordinated
666=Only one party involved

How well did the people who were working with your child and family involve you in the
service planning process? (F.1.a.)
Did they encourage you to bring someone to the meeting with you, perhaps for
support?

CMHI National Evaluation, Follow-up Assessment
Caregiver (I), February 2011
Phase VI

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Did they ask you whether there was anyone you did not want to be present in the
meeting?
Did they ask you to talk about what you thought were the most important concerns
for your child and family?
Did they encourage you to help develop your child’s and family’s goals and
objectives?
Did they give you a choice of services that you thought would be most helpful for your
child and family?
Were you able to turn down services that you did not want your child and family to
receive?
Overall, were you as involved in the service planning process as you think you should
have been?
5=Caregiver was involved in service planning in at least 6 ways AND respondent reported that involvement has been sufficient
4=Caregiver was involved in service planning in 5 ways OR involved in 6 ways but respondent reported that it could have been better
3=Caregiver was involved in service planning in 4 ways
2=Caregiver was involved in service planning in 3 ways
1=Caregiver was involved in service planning in fewer than 3 ways

12.

What about your child? How have the people working with your child and family
involved your child in planning his/her services? (F.2.a.)
If your child was not involved, do you think that it would have been helpful for your
child to be more involved? [Probe for whether it was appropriate for the child to be
involved given his/her challenges, age, or caregiver’s preference.]
If yes, how did they involve your child?
Did they encourage your child to bring someone to the meeting with you, perhaps for
support?
Did they ask your child whether there was anyone he/she did not want to be present in
the meeting?
Did they ask your child about what he/she thought were the most important
concerns?
Did they encourage him/her to participate in developing his/her goals and objectives?
Did they give him/her a choice of which services he/she wanted?
Was he/she able to turn down any services he/she didn’t want?

CMHS National Evaluation, Baseline Assessment
Caregiver (I), February 2011
Phase VI

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Overall, was your child as involved as you would have liked, or could there have
been more involvement?
5=Child was involved in service planning in at least 6 ways AND respondent reported that involvement has been sufficient
4=Child was involved in service planning in 5 ways OR involved in 6 ways but respondent reported that it could have been better
3=Child was involved in service planning in 4 ways
2=Child was involved in service planning in 3 ways
1=Child was involved in service planning in fewer than 3 ways
666=Caregiver reported it was not appropriate for child/youth to participate

13.

When you were working with (name of case manager/therapist) to plan services, did she/he talk
with you about your child’s strengths (his/her competencies /skills /interests and/ or
aspirations)? Would you mind giving me some examples of things you talked about?
(F.3.b.)
How were your child’s strengths used in planning his/her services? What could have
been done better?

5=Strengths explicitly discussed and at least three examples given of how strengths were incorporated into the service plan AND respondent
reported it could not have been better
4=Strengths explicitly discussed and two examples given of how strengths were incorporated into the service plan but respondent reported it
could have been better
3=Strengths explicitly discussed and one example given of how strengths were incorporated into the service plan
2=Strengths explicitly discussed but not (or very, very minimally) incorporated into the service plan
1=No discussion of strengths

14.

What services were planned for your child during the planning process? [List all
services planned.]

15.

How well did the services planned for your child meet his/her individual or specific
needs? (F.3.c.)
Were there any services that you thought your child needed but were not included in the
service plan? If yes, what were they?
Were there services included in your child’s service plan that you think he/she didn’t
really need? If yes, please explain.
On a scale from 1 to 5, with 5 being the best, how well would you say the service plan
developed for your child matched what your child really needed?

Respondent’s rating
5=Child’s needs matched extremely well
4=Child’s needs matched very well
3=Child’s needs matched moderately well
2=Child’s needs matched somewhat well
1=Child’s needs not matched well

16.

Interviewer’s rating
5=Child’s needs matched extremely well
4=Child’s needs matched very well
3=Child’s needs matched moderately well
2=Child’s needs matched somewhat well
1=Child’s needs not matched well

Did (name of case manager/therapist) talk with you about your family’s strengths? Would you
mind giving me some examples of things you talked about? (F.1.c.)
How did he/she use your family’s strengths in planning services for your family?
What could have been done better?

CMHS National Evaluation, Baseline Assessment
Caregiver (I), February 2011
Phase VI

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5=Strengths explicitly discussed and at least three examples given of how strengths were incorporated into the service plan AND respondent
reported it could not have been better
4=Strengths explicitly discussed and two examples given of how strengths were incorporated into the service plan but respondent reported it
could have been better
3=Strengths explicitly discussed and one example given of how strengths were incorporated into the service plan
2=Strengths explicitly discussed but not (or very, very minimally) incorporated into the service plan
1=No discussion of strengths

17.

When you were working with (name of case manager/therapist) to plan services, did he/she ever
talk with you about your family’s needs and the services or other kinds of supports
that you or other people in your family could use (for example, respite care, support
groups, family advocacy, sibling support, behavior management training)? (F.1.b.)
If yes, did (name of case manager/therapist) try to identify or put into place any services to meet
those needs? Please describe.
[List all services planned for the family.]
Were there any other services or supports that you and your family needed but were
not a part of your service plan?

5=Family needs were explicitly considered and services were planned that would fully meet their needs
4=Family needs were explicitly considered and services were planned that would meet most of their needs
3=Family needs were explicitly considered and services were planned that would meet some of their needs
2=Family needs considered, but no services were planned AND family reporting having need(s)
1=Family needs were not discussed (regardless of whether family reported having needs)
666=Family reporting having had no needs

18.

Did (name of case manager/therapist) ever ask you about your family’s culture and
background, for example, your family’s beliefs, (your tribe’s beliefs), values, religious
preferences, ideas about parenting, recreational activities, etc.? (F.4.a.)
If yes, would you mind giving me an example of some of the kinds of things you talked
about?
How do you think (name of case manager/therapist) used this information to plan services for
your child and family?
Overall, do you think that he/she did a good job planning services that fit with your
family’s background and culture? If no, what could have been done better?

5=Culture explicitly discussed and at least three examples given of how culture was incorporated into the service plan AND respondent reported
it could not have been better
4=Culture explicitly discussed and two examples given of how culture was incorporated into the service plan but respondent reported it could
have been better
3=Culture explicitly discussed and one example given of how culture was incorporated into the service plan
2=Culture explicitly discussed but not (or very, very minimally) incorporated into the service plan
1=No discussion of culture

19.a.

Does your family speak a language other than English? If yes, is this the language
you are most comfortable speaking? (F.4.c.)

CMHS National Evaluation, Baseline Assessment
Caregiver (I), February 2011
Phase VI

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If yes, was (name of case manager/therapist) able to speak to you in this language when you
were working with him/her to plan services?
If no, was someone there who could speak your language and interpret? Who?
5=Service planning process was conducted entirely in family’s preferred language
4=Service planning process was conducted in English but formal interpretation was provided by the grant
3=Service planning process was conducted in English but informal interpretation services provided by grant
2=Service planning process was conducted in English and family brought interpreter because no other option was available
1=Service planning process was conducted in English and no interpretation was conducted or any interpretation had to be done by a child in the
family
666=Not applicable. Family’s primary language is English

b.

[If family’s language preference is not English, ask:] What about when your child
and family were actually receiving the services? Were you able to get any services in
the language you are most comfortable with? (G.4.b)
If yes, which services were provided in your language and which were not? Were
there any services that you would have preferred were available in your language?
Were interpretation services provided to you? Who provided interpretation?

5=Key services were provided entirely in family’s preferred language
4=Key services were provided in English but formal interpretation was provided by the program
3=Key services were provided in English but informal interpretation services provided by program
2=Key services were provided conducted in English and family brought interpreter because no other option was available
1=Key services were provided in English and no interpretation was conducted or any interpretation had to be done by a child in the family
666=Not applicable. Family’s primary language is English

20.

Were any of the things you talked about with (name of case manager/therapist) ever written
down as in a service plan (such as the services you wanted, goals, strengths, needs,
etc.)?
1=No, 2=Yes

If yes, did you get a copy of the service plan? Did you have to ask for it or did you
automatically receive it?
If no copy received, were you able to see a copy of the service plan?
(NOTE TO INTERVIEWER: Questions 21-22 skipped)

Service Provision
23.

Has your child received all of the services that you and (name of case manager/therapist)
decided that s/he should have or that were written in the service plan? (G.3.a.)
[Refer back to Question 14 and check whether all services listed there were
received.]
If not, were services planned that you thought were important for your child to have that
he/she never received? Why do you think he/she has not received those services?

CMHS National Evaluation, Baseline Assessment
Caregiver (I), February 2011
Phase VI

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5=Child received all of the services that were planned
4=Child received most of the services that were planned including those that the caregiver said were most important
3=Child received many of the services that were planned OR received most of the planned services but has not yet received services the caregiver
identified as important
2=Child received a few of the services that were planned (importance of services not important here)
1=Child received no services outlined in the plan

24.

What about services planned for you or for other members of your family — have
you received all these services? (G.1.b.)
[Refer back to question 17 and check whether all services listed there were
received.]
If not, were there services planned that you thought were important for your family to
have that were never received? Why do you think your family has not received those
services?

5=Family received all of the services that were planned
4=Family received most of the services that were planned including all those that the caregiver said were most important
3=Family received many of the services that were planned OR received most of the planned services but has not yet received services the
caregiver identified as important
2=Family received a few of the services that were planned (importance of services not relevant)
1=Family received no services outlined in the plan
666=No services were planned for the family

25.

Were services scheduled at convenient times for your child and family? If no, please
explain. (G.7.b.)
What times would have worked better for you? Have you been able to get any services
in the evenings or on weekends if that were more convenient for you?
On a scale from 1 to 5, with 5 being the best, how convenient and/or flexible would
you say the scheduling of services has been?

Respondent’s rating
5=Extremely convenient
4=Very convenient
3=Moderately convenient
2=Somewhat convenient
1=Not at all convenient

26.

Interviewer’s rating
5=Extremely convenient
4=Very convenient
3=Moderately convenient
2=Somewhat convenient
1=Not at all convenient

Have the places or locations where your child and family received services been
convenient for you? (G.7.c.)
If not, what would have worked better? Have you ever had a choice or say in where you
wanted to receive services?
On a scale from 1 to 5, with 5 being the best, how convenient and/or flexible would
you say the location of services has been?

CMHS National Evaluation, Baseline Assessment
Caregiver (I), February 2011
Phase VI

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Respondent’s rating
5=Extremely convenient
4=Very convenient
3=Moderately convenient
2=Somewhat convenient
1=Not at all convenient

27.

Interviewer’s rating
5=Extremely convenient
4=Very convenient
3=Moderately convenient
2=Somewhat convenient
1=Not at all convenient

Have you ever had to pay out of pocket for any of the services that your child and
family received through (name of grant program) ? (G.7.e.)
If yes, which services? Has part of the cost of the services ever been covered by private
insurance, Medicaid, or other healthcare program?
Have there been any services that you thought were important for your child and
family but that you did not receive because of the cost?
On a scale from 1 to 5, (with 5 indicating that cost is not a barrier), how much of a
barrier to services has cost been?

Respondent’s rating
5=Not at all a barrier
4=Slightly a barrier
3=Somewhat a barrier
2=Moderately of a barrier
1=Largely a barrier

28.

Interviewer’s rating
5=Not at all a barrier
4=Slightly a barrier
3=Somewhat a barrier
2=Moderately of a barrier
1=Largely a barrier

After deciding which services your child and family would receive, how long has it
usually taken (in calendar days) to actually receive those services? [Probe for
shortest, longest, and average wait for services received since entering (name of grant
program) ] (G.7.f.)
What about the services that you considered most important? How long have you had to
wait for those services?
In general, what have you thought about the length of time it took to get the services
once they were planned?

5=No or almost no wait for non-emergent services. Services received in 7 days or fewer.
4=Some wait for non-emergent services. Services received between 8 to 14 days.
3=Moderate wait for non-emergent services. Services received between 15 to 21 days.
2=Long wait for non-emergent services. Services received between 22 and 28 days
1=Very long wait for non-emergent services. Services received in more than 28 days.

(NOTE TO INTERVIEWER: Questions 28b skipped)

29.

Have you ever received any kind of transportation assistance (taxi fare, bus tokens,
shuttle bus, a ride, etc.) from (name of grant program) ? Who helped you with this? (G.7.d.)
Have you been able to get help with transportation when you needed it — was it easy
to ask for, easy to get?
Have you had any problems with the assistance?

5=Transportation assistance was always or almost always available when the family needed it. Family had no trouble accessing this service and
reported little or no problems.
4=Transportation assistance was most often available when the family needed it. Family reported having some trouble with transportation
assistance.
CMHS National Evaluation, Baseline Assessment
Caregiver (I), February 2011
Phase VI

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3=Family used transportation assistance, but reported having moderate trouble with transportation assistance.
2=Family used transportation assistance, but reported considerable difficulties accessing the service.
1=Family reported needing transportation assistance, but could not access it.
666=Family reported never needing or wanting to use transportation services.

30.

How well do you think that all the staff and people serving your child and family have
worked with each other to make sure that your child’s and family’s services have been
coordinated? (G.6.a.)
Do you think that they all have known who has been involved with your child and
family and what their different roles/jobs have been?
Have they worked together to make sure there have been no scheduling problems
with your child and family’s appointments?
Have they shared information with each other or have you often thought that you have
to repeat everything to everybody because the providers and staff have not
communicated well with each other?
Overall, do you feel that your child’s and family’s services have been coordinated
well, or could they have done a better job? Can you give me some examples of
problems?

5=Extremely well coordinated. No problems reported.
4=Very well coordinated. Minor problems reported.
3=Moderately well coordinated. Some problems reported.
2=Somewhat coordinated. Considerable problems reported.
1=Poorly coordinated. Major problems reported.
666=Only one party involved.

(NOTE TO INTERVIEWER: Question 31 skipped)

32.

What have the different service providers who work with your child and family done to
include you in your child’s services and treatment planning? (G.1.a.)
For example, have they usually encouraged you to offer your ideas about your child’s
treatment and other services?
Have they considered you to be the primary decisionmaker about your child’s
treatment and other services?
Have they encouraged you to let them know when something was not working well for
your child and family?
Have they asked you for suggestions about changes that could be made to improve
your child’s or family’s care?
Have the providers often asked you to participate in services for your child and family?
If yes, please describe.
Have the different providers usually kept you informed about what was going on in
services and keep you updated about your child’s and family’s progress, such as how
things were going, what was working, what wasn’t?

CMHS National Evaluation, Baseline Assessment
Caregiver (I), February 2011
Phase VI

10

Overall, could the staff have done a better job keeping you involved in your child’s
and family’s services?
5=Caregiver was involved in service provision in at least 4 ways AND respondent reported that involvement has been sufficient
4=Caregiver was involved in service provision in 3 ways OR involved in 4 ways but respondent reported that it could have been better
3=Caregiver was involved in service provision in 2 ways
2=Caregiver was involved in service provision in 1 way
1=Caregiver was not involved in service provision

(NOTE TO INTERVIEWER: Questions 33-39 skipped)

Summary
40.

On a scale from 1 to 5, with 5 being the best, how much would you say (name of grant
program) has helped your child?
5=Very much
4=A lot
3=Moderately
2=Somewhat
1=Not at all

How much would you say

(name of grant program)

has helped your family?

5=Very much
4=A lot
3=Moderately
2=Somewhat
1=Not at all

41.

What has been the best thing about receiving services through

42.

Do you have any suggestions or recommendations for how
improve the way that it serves children and families?

43.

On a scale from 1 to 5, with 5 being the best, how well do you think
meeting the needs of children and families?

(name of grant program)?
(name of grant program)

could

(name of grant program)

is

5=Extremely well
4=Very well
3=Moderately well
2=Somewhat well
1=Not well at all

Those are all of the questions I have for you. Is there anything that I did not cover that you think
is important for us to know about (name of grant program)?
Thank you for taking the time to answer my questions. Do you have any questions for me?

CMHS National Evaluation, Baseline Assessment
Caregiver (I), February 2011
Phase VI

11

Attachment D: Longitudinal Child and Family Outcome Study and Service
Experience Study

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 22 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

CAREGIVER INFORMATION QUESTIONNAIRE,
Revised: Caregiver—Intake (CIQ–RC–I)
/

CIQDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

1 = Intake

CIQRESP (Respondent for interview)

1 = Caregiver (child’s caregiver in a family, household
environment)

CIQINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

CIQMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

CIQLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Date last modified: September 2012

Caregiver Information Questionnaire,
Revised: Caregiver—Intake (CIQ–RC–I)

CHILD ID:

I am going to ask you some questions about (child’s name)’s background and family and about services
that (child’s name) has received. Please answer these questions as best you can, and try to be as complete
as possible in your answers. To begin, I’d like to ask you a few general questions about you and (child’s
name)’s family.
1.

What is your relationship to (child’s name)?
1 = Biological parent
2 = Adoptive/step-parent
3 = Foster parent
4 = A live-in partner of parent
5 = Sibling (biological, step, etc.)
6 = Aunt or uncle
7 = Grandparent
8 = Cousin
9 = Other family relative
10 = Friend (adult friend)
11 = Other—please specify __________________________
1a.

What is your gender?
1 = Male
2 = Female

2.

What is your age?
_____ years

3.

Are you of Hispanic or Latino cultural/ethnic background?
1 = No [GO TO QUESTION #4]
2 = Yes
3a.

Which group(s) describes your Hispanic or Latino cultural/ethnic background? Are you . . .
[Select one or more]
1 = Mexican, Mexican American, or Chicano
2 = Puerto Rican
3 = Cuban
4 = Dominican
5 = Central American
6 = South American
7 = Other—please specify __________________________

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
1

Caregiver Information Questionnaire,
Revised: Caregiver—Intake (CIQ–RC–I)

CHILD ID:

4.

Which group(s) describes you? Are you . . . [Select one or more]
1 = American Indian or Alaska Native
2 = Asian
3 = Black or African American
4 = Native Hawaiian or Other Pacific Islander
5 = White
[NOTE TO INTERVIEWER: Do not ask if there is another group that describes the respondent. If
the respondent is unable to select from options 1–5 and he/she provides an alternate group, record
that answer on the line by option 6.]
6 = Other—please specify __________________________

[NOTE TO INTERVIEWER: For Questions #5–5c, do not read the response options to the caregiver.]
5.

What language or languages do you and (child’s name) speak? [Select all that apply]
1 = English
2 = Spanish
3 = Other—please specify __________________________
5a.

When you are at home, or with your family, what language do you usually speak with your
child?
1 = English
2 = Spanish
3 = Other—please specify __________________________

5b.

When you are at home, or with your family, what language does your child usually speak
with you?
1 = English
2 = Spanish
3 = Other—please specify __________________________

5c.

Which is (child’s name)’s most preferred language?
1 = English
2 = Spanish
3 = Other—please specify __________________________

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
2

Caregiver Information Questionnaire,
Revised: Caregiver—Intake (CIQ–RC–I)

CHILD ID:

6.

What is the highest level of education you have completed?
_____
[IF FROM KINDERGARTEN TO 11TH GRADE, enter 0–11] 0–11 = Kindergarten–11th grade
[IF FINISHED HIGH SCHOOL, select the appropriate category below]
12 = High school diploma or GED
13 = Associate degree
14 = Some college, no degree
15 = Bachelor’s degree
16 = Master’s degree
17 = Professional school degree
18 = Doctoral degree

7.

Other than a primary caregiver, does (child’s name) currently have a close relationship with an adult
who provides advice and support?
1 = No
2 = Yes

8.

Who has legal custody of (child’s name)?
1 = Two biological parents or one biological and one step or adoptive parent
2 = Biological mother only
3 = Biological father only
4 = Adoptive parent(s)
5 = Sibling(s)
6 = Aunt and/or uncle
7 = Grandparent(s)
8 = Friend (adult friend)
9 = Ward of the State
10 = Other—please specify __________________________

9.

Including (child’s name), what is the total number of children (under age 18) in the household
where (child’s name) is currently living?
_____ [RECORD 0, IF NONE]

10.

What is the total number of adults (age 18 or older) in the household where (child’s name) is
currently living? Include (child’s name) in this total if (child’s name) is age 18 or older.
_____ [RECORD 0, IF NONE]

11.

Approximately how many days in the past 6 months did (child’s name) live in your household?
_____ days [6 months = 180 days]

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
3

Caregiver Information Questionnaire,
Revised: Caregiver—Intake (CIQ–RC–I)

CHILD ID:

[CARD 1]
12.

What is the annual household income of (child’s name)’s family?
For this question, (child’s name)’s family should be considered to be the family with whom he/she
has lived for the majority of the past 6 months. For example, if (child’s name) has lived with a
foster family for most of the past 6 months, we are interested in knowing the foster family’s income.
[NOTE TO INTERVIEWER: Prompt respondent to consider all sources of pre-tax (gross) income,
including wages, child support, alimony, and public assistance. The family household income
should include the pre-tax incomes of all individuals who live with the child and contribute
financially to the child’s care.]
1 = Less than $5,000
2 = $5,000–$9,999
3 = $10,000–$14,999
4 = $15,000–$19,999
5 = $20,000–$24,999
6 = $25,000–$34,999
7 = $35,000–$49,999
8 = $50,000–$74,999
9 = $75,000–$99,999
10 = $100,000 and over

13.

At any time in the past 6 months, did you have a paid job (formal or informal), including selfemployment?
1 = No [GO TO QUESTION #13g]
2 = Yes
13a. In the past 6 months, how many months did you work?
_____ months
13b. In an average month, about how many weeks do you work?
_____ weeks
13c. In an average week, about how many days do you work?
_____ days
13d. In an average day, about how many hours do you work?
_____ hours
13e. About how much money do you make per week?
$__________
13f. In the past 6 months, how many days did you miss work due to (child’s name)’s emotional
and behavioral problems, if any?
_____ days [GO TO QUESTION #14]

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
4

Caregiver Information Questionnaire,
Revised: Caregiver—Intake (CIQ–RC–I)

CHILD ID:

13g. What was the primary barrier that prevented you from working for pay during the past 6
months?
1 = I was not interested in employment during that period
2 = In school or other training
3 = Could not find any work at the desired pay
4 = Transportation problems
5 = Childcare problems
6 = My health problems/disability
7 = (Child’s name)’s behavioral and emotional problems
8 = Other family responsibilities
9 = Other—please specify ____________________________________________
13h. Were there other barriers that prevented you from working for pay during the past 6 months?
1 = No [GO TO QUESTION #14]
2 = Yes
13i. What were the other barriers that prevented you from working for pay during the past 6
months? [Select all that apply]
1 = I was not interested in employment during that period
2 = In school or other training
3 = Could not find any work at the desired pay
4 = Transportation problems
5 = Childcare problems
6 = My health problems/disability
7 = (Child’s name)’s behavioral and emotional problems
8 = Other family responsibilities
9 = Other—please specify ____________________________________________

[CARD 2]
Never
14.

About
half the Most of
Sometimes
time
the time Always

How often do you have the following?
14a. Time to spend with your family

1

2

3

4

5

14b. Money to pay for basic needs like
housing, food, or clothing

1

2

3

4

5

14c. Money to pay for special things like toys,
entertainment, or vacations

1

2

3

4

5

14d. Time to spend alone or with friends

1

2

3

4

5

Now I need to ask some questions concerning (child’s name)’s history.

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
5

Caregiver Information Questionnaire,
Revised: Caregiver—Intake (CIQ–RC–I)

CHILD ID:

15.

Has (child’s name) ever experienced or witnessed an event that caused, or threatened to cause,
serious harm to him or herself or to someone else? [Select all that apply]
1 = Car accident
2 = Other accident
3 = Fire
4 = Storm
5 = Physical illness
6 = Physical assault
7 = Sexual assault
8 = Any other event—please specify __________________________
9 = Has not experienced or witnessed a traumatic event [GO TO QUESTION #17]

I’m going to read to you a list of behaviors that describe children. After I read each behavior, tell me
which description best describes (child’s name) now or within the past 6 months. Rate each statement by
the following criteria: the statement is very true or often true, somewhat or sometimes true, or not true of
(child’s name). Please answer all items as well as you can even if some do not seem to apply to (child’s
name). The term “event” refers to the most stressful experience that you have described above.

[CARD 3]

16.

Not
true

Somewhat or
sometimes
true

Very true
or often
true

15a. Child gets very upset if reminded of the event.

0

1

2

15b. Child reports more physical complaints when reminded
of the event. For example, headaches, stomachaches,
nausea, difficulty breathing.

0

1

2

15c. Child reports that he or she does not want to talk about
the event.

0

1

2

15d. Child startles easily. For example, he or she jumps when
hears sudden or loud noises.

0

1

2

[If Physical assault selected in #15] In the past 6 months, has (child’s name) been physically
abused?
1 = No
2 = Yes
16a. [If Sexual assault selected in #15] In the past 6 months, has (child’s name) been sexually
abused?
1 = No
2 = Yes

17.

Has (child’s name) ever run away without his/her caregiver knowing where he/she was?
[NOTE TO INTERVIEWER: This could be the current caregiver or a past caregiver.]
1 = No [GO TO QUESTION #18]
2 = Yes

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
6

Caregiver Information Questionnaire,
Revised: Caregiver—Intake (CIQ–RC–I)

CHILD ID:

17a. In the past 6 months, has (child’s name) run away without his/her caregiver knowing where
he/she was?
[NOTE TO INTERVIEWER: This could be the current caregiver or a past caregiver.]
1 = No
2 = Yes
18.

Has (child’s name) ever had a problem with substance abuse, including alcohol and/or drugs?
1 = No [GO TO QUESTION #19]
2 = Yes
18a. In the past 6 months, has (child’s name) had a problem with substance abuse, including
alcohol and drugs?
1 = No
2 = Yes

19.

Has (child’s name) ever talked about committing suicide?
1 = No [GO TO QUESTION #20]
2 = Yes
19a. In the past 6 months, has (child’s name) talked about committing suicide?
1 = No
2 = Yes

20.

Has (child’s name) ever attempted suicide?
1 = No [GO TO QUESTION #21]
2 = Yes
20a. How many times has (child’s name) attempted suicide?
_____ times
20b. In the past 6 months, has (child’s name) attempted suicide?
1 = No [GO TO QUESTION #21]
2 = Yes
20c. In the past 6 months, how many times has (child’s name) attempted suicide?
_____ times

Now I need to ask some questions concerning (child’s name)’s family and household history. These
questions are about (child’s name)’s biological family and the people who live, or lived, in (child’s
name)’s household. For these questions, when you think about (child’s name)’s households, do not
include residential treatment centers or group homes in which (child’s name) may have lived.
21.

Has (child’s name) ever been exposed to domestic violence or spousal abuse, of which (child’s
name) was not the direct target?
1 = No [GO TO QUESTION #22]
2 = Yes

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
7

Caregiver Information Questionnaire,
Revised: Caregiver—Intake (CIQ–RC–I)

CHILD ID:

21a. In the past 6 months, has (child’s name) been exposed to domestic violence or spousal abuse,
of which (child’s name) was not the direct target?
1 = No
2 = Yes
22.

Has anyone in (child’s name)’s biological family ever been diagnosed with depression or shown
signs of depression? By biological family, I mean (child’s name)’s biological parents,
grandparents, and siblings.
1 = No
2 = Yes
22a. Has (child’s name) ever lived in a household in which someone showed signs of being
depressed?
1 = No [GO TO QUESTION #23]
2 = Yes
22b. In the past 6 months, has (child’s name) lived in a household in which one of the household
members showed signs of being depressed?
1 = No [GO TO QUESTION #23]
2 = Yes
22c. Was the person who showed signs of being depressed involved in providing care and
supervision to (child’s name)?
1 = No
2 = Yes

23.

Has anyone in (child’s name)’s biological family had a mental illness, other than depression? By
biological family, I mean (child’s name)’s biological parents, grandparents, and siblings.
1 = No
2 = Yes
23a. Other than depression, has (child’s name) ever lived in a household in which someone had a
mental illness?
1 = No [GO TO QUESTION #24]
2 = Yes
23b. In the past 6 months, has (child’s name) lived in a household in which one of the household
members had a mental illness other than depression?
1 = No [GO TO QUESTION #24]
2 = Yes
23c. Was the person with a mental illness involved in providing care and supervision to (child’s
name)?
1 = No
2 = Yes

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
8

Caregiver Information Questionnaire,
Revised: Caregiver—Intake (CIQ–RC–I)

CHILD ID:

24.

Has (child’s name) ever lived in a household in which someone had been convicted of a crime?
1 = No [GO TO QUESTION #25]
2 = Yes
24a. In the past 6 months, have any members of (child’s name)’s household been convicted of a
crime?
1 = No
2 = Yes

25.

Has anyone in (child’s name)’s biological family had a drinking or drug problem? By biological
family, I mean (child’s name)’s biological parents, grandparents, and siblings.
1 = No
2 = Yes
25a. Has (child’s name) ever lived in a household in which someone had a drinking or drug
problem?
1 = No [GO TO QUESTION #26]
2 = Yes
25b. In the past 6 months, has (child’s name) lived in a household in which one of the household
members had a drinking or drug problem?
1 = No [GO TO QUESTION #26]
2 = Yes
25c. Was the person with a drinking or drug problem involved in providing care and supervision
to (child’s name)?
1 = No
2 = Yes

I will now read you several statements. For each of the statements, please tell me whether each statement
is True or False in describing your experience.
True

False

26.

I felt free to do what I wanted about getting mental health treatment for
(child’s name).

1

2

27.

I chose to get mental health treatment for (child’s name).

1

2

28.

It was my idea to get mental health treatment for (child’s name).

1

2

29.

I had a lot of control over whether (child’s name) got mental health
treatment.

1

2

30.

I had more influence than anyone else on whether (child’s name) got mental
health treatment.

1

2

Now I’m going to ask you some questions related to (child’s name)’s health.

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
9

Caregiver Information Questionnaire,
Revised: Caregiver—Intake (CIQ–RC–I)

CHILD ID:

31.

Does (child’s name) have recurring or chronic physical health problems such as allergies, asthma,
migraine headaches, diabetes, epilepsy, cancer, etc.?
1 = No [GO TO QUESTION #33]
2 = Yes

32.

What recurring or chronic physical health problems does (child’s name) have? [Select all that
apply]
1 = Allergies
2 = Asthma
3 = Cancer
4 = Cerebral palsy
5 = Diabetes
6 = Epilepsy
7 = Migraine headaches
8 = Heart condition
9 = High blood pressure
10 = Overweight
11 = Sickle cell anemia
12 = Spina bifida
13 = Thyroid problems
14 = Other—please specify ____________________________________________
32a. Now or in the past 6 months, has (child’s name) taken medication related to his/her (name of
child’s physical health problems)?
1 = No
2 = Yes
32b. During the past 6 months, have the regular activities (child’s name) participates in (such as
school, social activities, participation in treatment for emotional or behavioral problems,
etc.) been disrupted because of problems related to his/her recurring or chronic physical
health problems?
1 = No
2 = Yes

33.

In the past 6 months, how many times did (child’s name) see a doctor or other primary health care
provider for a physical health problem, not during an emergency room visit?
_____ times [RECORD 0, IF NONE]

34.

During the past 6 months, how many times did (child’s name) have to go to the emergency room to
seek treatment for a physical health problem?
_____ times [RECORD 0, IF NONE]
34a. During the past 6 months, how many times did (child’s name) have to go to the emergency
room to seek treatment as a result of his/her behavioral or emotional problem?
_____ times [RECORD 0, IF NONE]

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
10

Caregiver Information Questionnaire,
Revised: Caregiver—Intake (CIQ–RC–I)

CHILD ID:

35.

During the past 6 months, how many times was (child’s name) hospitalized for a physical health
problem?
_____ times [RECORD 0, IF NONE]
35a. [IF 1 OR MORE] What is the total number of days that (child’s name) was hospitalized for a
physical problem in the past 6 months?
_____ days

36.

Has (child’s name) had a routine physical health exam in the past 6 months?
1 = No
2 = Yes

37.

Does (child’s name) have a primary health care provider?
1 = No [GO TO QUESTION #38]
2 = Yes
37a. What type of provider is (child’s name)’s primary health care provider?
1 = Pediatrician
2 = Physician other than a pediatrician
3 = Physician’s assistant
4 = Nurse practitioner
5 = No consistent primary health care provider
6 = Tribal healer/alternative health practitioner
7 = Other—please specify ____________________________________________

38.

Do you, or any other member of your household other than (child’s name), have recurring or
chronic physical health problems such as allergies, asthma, migraine headaches, diabetes, epilepsy,
cancer, etc.?
1 = No [GO TO QUESTION #39]
2 = Yes

[CARD 4]
38a. In the past 6 months, how much has your ability to care for (child’s name) been affected by
the chronic health problems of these household members?
1 = Not at all
2 = A little bit
3 = A moderate amount
4 = Quite a bit
5 = A great deal
Sometimes a doctor or psychiatrist prescribes medication for children to help reduce their emotional or
behavioral symptoms. For example, Adderall may be prescribed for Attention-Deficit Disorder.

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
11

Caregiver Information Questionnaire,
Revised: Caregiver—Intake (CIQ–RC–I)

CHILD ID:

39.

Now or in the past 6 months, has (child’s name) taken any medication related to his/her emotional
or behavioral symptoms?
1 = No [GO TO QUESTION #40]
2 = Yes

[CARD 5]
39a. Who prescribed these medications 39b. In the past 6 months, how many times did
for (child’s name)? [Select all that
you/(child’s name) see this doctor for follow-up on
these prescribed medications?
apply]
More
than 6
times

Not at
all

1 time

2 times

1 = Primary care physician/family
physician

1

2

3

4

5

6

2 = Child psychiatrist

1

2

3

4

5

6

3 = General psychiatrist

1

2

3

4

5

6

4 = Pediatrician

1

2

3

4

5

6

1

2

3

4

5

6

1

2

3

4

5

6

3–5 times 6 times

5 = Other—please specify
________________________
6 = Other—please specify
________________________

[NOTE TO INTERVIEWER: Do not read the medications in the medication table to the caregiver. Record
the caregiver’s response and then circle the appropriate responses in the table.]
39c. [IF YES TO #39] Please tell me the medication(s) that (child’s name) is currently taking or
has taken in the past 6 months.
__________________________________________________________________________
[Select all that apply]
Taking currently or
in the past 6 months
Medication Category

No

Yes

Abilify (aripiprazole)

1

2

Adderall (amphetamine mixed salts)

1

2

Catapres (clonidine)

1

2

Celexa (citalopram)

1

2

Concerta (methylphenidate)

1

2

Daytrana (methylphenidate transdermal system)

1

2

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
12

Caregiver Information Questionnaire,
Revised: Caregiver—Intake (CIQ–RC–I)

CHILD ID:

Taking currently or
in the past 6 months
Medication Category

No

Yes

Depakote (valproic acid and derivatives)

1

2

Desyrel (trazodone)

1

2

Dexedrine (dextroamphetamine)

1

2

Effexor (venlafaxine)

1

2

Eskalith (lithium)

1

2

Focalin (dexmethylphenidate)

1

2

Geodon (ziprasidone)

1

2

Haldol (haloperidol)

1

2

Klonopin (clonazepam)

1

2

Lamictal (lamotrigine)

1

2

Lexapro (escitalopram)

1

2

Lithobid (lithium)

1

2

Lithonate (lithium)

1

2

Metadate (methylphenidate)

1

2

Neurontin (gabapentin)

1

2

Orap (pimozide)

1

2

Paxil (paroxetine)

1

2

Prozac (fluoxetine)

1

2

Remeron (mirtazapine)

1

2

Risperdal (risperidone)

1

2

Ritalin (methylphenidate)

1

2

Seroquel (quetiapine)

1

2

Strattera (atomoxetine)

1

2

Symbyax (olanzapine and fluoxetine)

1

2

Tegretol (carbamazepine)

1

2

Tenex (guanfacine)

1

2

Topamax (topiramate)

1

2

Trileptal (oxcarbazepine)

1

2

Vyvanse (lisdexamfetamine dimesylate)

1

2

Wellbutrin (bupropion)

1

2

Xanax (alprazolam)

1

2

Zoloft (sertraline)

1

2

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
13

Caregiver Information Questionnaire,
Revised: Caregiver—Intake (CIQ–RC–I)

CHILD ID:

Taking currently or
in the past 6 months
Medication Category

No

Yes

Zyprexa (olanzapine)

1

2

Other—please specify __________________________

1

2

I will now read you several statements. These statements are about any medications that (child’s name) is
currently taking, or has taken in the past 6 months, for his/her emotional or behavioral symptoms. For
each of the statements, please tell me how strongly you agree that the statement reflects your experience.

[CARD 6]
Strongly
Strongly
disagree Disagree Undecided Agree
agree
39d. I see benefits from (child’s name) taking
his/her medication.

1

2

3

4

5

39e. I understand why (child’s name) takes
his/her medication.

1

2

3

4

5

39f. I know what (child’s name)’s medication
is supposed to do for him/her.

1

2

3

4

5

39g. I had a choice in the medication that
(child’s name) takes.

1

2

3

4

5

39h. (Child’s name) takes his/her medication
the way he/she is supposed to.

1

2

3

4

5

39i. I feel comfortable about (child’s name)
taking medication.

1

2

3

4

5

Now I am going to ask you some questions about your family and about peer support that you may be
receiving from a family advocate, parent partner, or family liaison. This type of support is typically
received from another family member who is trained to work with families.
40.

Do you have a family advocate/parent partner/family liaison/other name?
1 = No [GO TO QUESTION #45]
2 = Yes

[CARD 7]
41.

In the past 6 months, how often did you meet with your (title of family advocate)?
1 = Never
2 = Not very often
3 = Sometimes
4 = Often
5 = Very often

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
14

Caregiver Information Questionnaire,
Revised: Caregiver—Intake (CIQ–RC–I)

CHILD ID:

No
42.

Yes

In the past 6 months, did the (title of family advocate) participate or assist you in any of the
following activities:
42a. Assistance with finances (e.g., budgeting, obtaining flex funds)

1

2

42b. Assistance with transportation

1

2

42c. Assistance with obtaining basic needs (e.g., housing, clothes, food)

1

2

42d. Dealing with agencies or getting services (e.g., child welfare, court,
schools/IEP, medical care, legal assistance)

1

2

42e. Obtaining employment or education services for you (e.g., resume
assistance, job training)

1

2

42f. Obtaining employment or education services for your child

1

2

42g. Provided you with social or emotional support

1

2

42h. Parenting skills/assistance

1

2

42i. Other—please specify _____________________________________

1

2

[CARD 8]
43.

In the past 6 months, how well did the (title of family advocate) address the issues brought to
his/her attention?
1 = Not at all well
2 = Somewhat well
3 = Moderately well
4 = Very well
5 = Extremely well

[CARD 9]
44.

In the past 6 months, how available was your (title of family advocate) when you needed him/her?
1 = Not at all
2 = Somewhat
3 = Moderately
4 = Very much
5 = Extremely

[CARD 7]
45.

In the past 6 months, how often did your family do things together outside of your home?
1 = Never
2 = Not very often
3 = Sometimes
4 = Often
5 = Very often

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
15

Caregiver Information Questionnaire,
Revised: Caregiver—Intake (CIQ–RC–I)

CHILD ID:

46.

In the past 6 months, how often did your family spend time together as a family?
1 = Never
2 = Not very often
3 = Sometimes
4 = Often
5 = Very often

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
16

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 17 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

CAREGIVER INFORMATION QUESTIONNAIRE,
Revised: Caregiver—Follow-Up (CIQ–RC–F)
/

CIQDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

CIQRESP (Respondent for interview)

1 = Caregiver (child’s caregiver in a family, household
environment)

CIQINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

CIQMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

CIQLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Date last modified: September 2012

Caregiver Information Questionnaire,
Revised: Caregiver—Follow-Up (CIQ–RC–F)

CHILD ID:

I am going to ask you some questions about (child’s name)’s background and family and about services
that (child’s name) has received. Please answer these questions as best you can, and try to be as complete
as possible in your answers.
0.

Have you ever answered questions about (child’s name) and/or your family for this study before?
1 = No [GO TO QUESTION #1]
2 = Yes

[CARD 1]
0a.

When did you answer these questions?

[NOTE TO INTERVIEWER: Circle all that apply. To prompt the respondent, identify the actual
time period for each of the answer choices. For example, “About 6 months ago would have been
March 15.”]
1 = About 6 months ago
2 = About 12 months ago
3 = About 18 months ago
4 = About 24 months ago
5 = Other—please specify __________________________
[GO TO QUESTION #8]
To begin, I’d like to ask you a few general questions about (child’s name)’s family.
1.

What is your relationship to (child’s name)?
1 = Biological parent
2 = Adoptive/step-parent
3 = Foster parent
4 = A live-in partner of parent
5 = Sibling (biological, step, etc.)
6 = Aunt or uncle
7 = Grandparent
8 = Cousin
9 = Other family relative
10 = Friend (adult friend)
11 = Other—please specify __________________________
1a.

What is your gender?
1 = Male
2 = Female

2.

What is your age?
_____ years

3.

Are you of Hispanic or Latino cultural/ethnic background?
1 = No [GO TO QUESTION #4]
2 = Yes

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
1

Caregiver Information Questionnaire,
Revised: Caregiver—Follow-Up (CIQ–RC–F)

CHILD ID:

3a.

Which group(s) describes your Hispanic or Latino cultural/ethnic background? Are you . . .
[Select one or more]
1 = Mexican, Mexican American, or Chicano
2 = Puerto Rican
3 = Cuban
4 = Dominican
5 = Central American
6 = South American
7 = Other—please specify __________________________

4.

Which group(s) describes you? Are you . . . [Select one or more]
1 = American Indian or Alaska Native
2 = Asian
3 = Black or African American
4 = Native Hawaiian or Other Pacific Islander
5 = White
[NOTE TO INTERVIEWER: Do not ask if there is another group that describes the respondent. If
the respondent is unable to select from options 1–5 and he/she provides an alternate group, record
that answer on the line by option 6.]
6 = Other—please specify __________________________

[NOTE TO INTERVIEWER: Questions #5–5c are skipped, as they are not applicable at follow-up.]
6.

What is the highest level of education you have completed?
_____
[IF FROM KINDERGARTEN TO 11TH GRADE, enter 0–11] 0–11 = Kindergarten–11th grade
[IF FINISHED HIGH SCHOOL, select the appropriate category below]
12 = High school diploma or GED
13 = Associate degree
14 = Some college, no degree
15 = Bachelor’s degree
16 = Master’s degree
17 = Professional school degree
18 = Doctoral degree

7.

Other than a primary caregiver, does (child’s name) currently have a close relationship with an adult
who provides advice and support?
1 = No
2 = Yes

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
2

Caregiver Information Questionnaire,
Revised: Caregiver—Follow-Up (CIQ–RC–F)

CHILD ID:

8.

Who has legal custody of (child’s name)?
1 = Two biological parents or one biological and one step or adoptive parent
2 = Biological mother only
3 = Biological father only
4 = Adoptive parent(s)
5 = Sibling(s)
6 = Aunt and/or uncle
7 = Grandparent(s)
8 = Friend (adult friend)
9 = Ward of the State
10 = Other—please specify __________________________

9.

Including (child’s name), what is the total number of children (under age 18) in the household
where (child’s name) is currently living?
_____ [RECORD 0, IF NONE]

10.

What is the total number of adults (age 18 or older) in the household where (child’s name) is
currently living? Include (child’s name) in this total if (child’s name) is age 18 or older.
_____ [RECORD 0, IF NONE]

11.

Approximately how many days in the past 6 months did (child’s name) live in your household?
_____ days [6 months = 180 days]

[CARD 2]
12.

What is the annual household income of (child’s name)’s family?
For this question, (child’s name)’s family should be considered to be the family with whom he/she
has lived for the majority of the past 6 months. For example, if (child’s name) has lived with a
foster family for most of the past 6 months, we are interested in knowing the foster family’s income.
[NOTE TO INTERVIEWER: Prompt respondent to consider all sources of pre-tax (gross) income,
including wages, child support, alimony, and public assistance. The family household income
should include the pre-tax incomes of all individuals who live with the child and contribute
financially to the child’s care.]
1 = Less than $5,000
2 = $5,000–$9,999
3 = $10,000–$14,999
4 = $15,000–$19,999
5 = $20,000–$24,999
6 = $25,000–$34,999
7 = $35,000–$49,999
8 = $50,000–$74,999
9 = $75,000–$99,999
10 = $100,000 and over

13.

At any time in the past 6 months, did you have a paid job (formal or informal), including selfemployment?
1 = No [GO TO QUESTION #13g]
2 = Yes

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
3

Caregiver Information Questionnaire,
Revised: Caregiver—Follow-Up (CIQ–RC–F)

CHILD ID:

13a. In the past 6 months, how many months did you work?
_____ months
13b. In an average month, about how many weeks do you work?
_____ weeks
13c. In an average week, about how many days do you work?
_____ days
13d. In an average day, about how many hours do you work?
_____ hours
13e. About how much money do you make per week?
$__________
13f. In the past 6 months, how many days did you miss work due to (child’s name)’s emotional
and behavioral problems, if any?
_____ days [GO TO QUESTION #14]
13g. What was the primary barrier that prevented you from working for pay during the past 6
months?
1 = I was not interested in employment during that period
2 = In school or other training
3 = Could not find any work at the desired pay
4 = Transportation problems
5 = Childcare problems
6 = My health problems/disability
7 = (Child’s name)’s behavioral and emotional problems
8 = Other family responsibilities
9 = Other—please specify ____________________________________________
13h. Were there other barriers that prevented you from working for pay during the past 6 months?
1 = No [GO TO QUESTION #14]
2 = Yes
13i. What were the other barriers that prevented you from working for pay during the past 6
months? [Select all that apply]
1 = I was not interested in employment during that period
2 = In school or other training
3 = Could not find any work at the desired pay
4 = Transportation problems
5 = Childcare problems
6 = My health problems/disability
7 = (Child’s name)’s behavioral and emotional problems
8 = Other family responsibilities
9 = Other—please specify ____________________________________________

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
4

Caregiver Information Questionnaire,
Revised: Caregiver—Follow-Up (CIQ–RC–F)

CHILD ID:

[CARD 3]
Never
14.

About
half the Most of
Sometimes
time
the time Always

How often do you have the following?
14a. Time to spend with your family

1

2

3

4

5

14b. Money to pay for basic needs like
housing, food, or clothing

1

2

3

4

5

14c. Money to pay for special things like toys,
entertainment, or vacations

1

2

3

4

5

14d. Time to spend alone or with friends

1

2

3

4

5

Now I need to ask some questions concerning (child’s name)’s history.
15.

In the past 6 months, has (child’s name) experienced or witnessed an event that caused, or
threatened to cause, serious harm to him or herself or to someone else? [Select all that apply]
1 = Car accident
2 = Other accident
3 = Fire
4 = Storm
5 = Physical illness
6 = Physical assault
7 = Sexual assault
8 = Any other event—please specify __________________________
9 = Has not experienced or witnessed a traumatic event [GO TO QUESTION #17a]

I’m going to read to you a list of behaviors that describe children. After I read each behavior, tell me
which description best describes (child’s name) now or within the past 6 months. Rate each statement by
the following criteria: the statement is very true or often true, somewhat or sometimes true, or not true of
(child’s name). Please answer all items as well as you can even if some do not seem to apply to (child’s
name). The term “event” refers to the most stressful experience that you have described above.

[CARD 4]
Not
true

Somewhat or
sometimes
true

Very true
or often
true

15a. Child gets very upset if reminded of the event.

0

1

2

15b. Child reports more physical complaints when reminded
of the event. For example, headaches, stomachaches,
nausea, difficulty breathing.

0

1

2

15c. Child reports that he or she does not want to talk about
the event.

0

1

2

15d. Child startles easily. For example, he or she jumps when
hears sudden or loud noises.

0

1

2

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
5

Caregiver Information Questionnaire,
Revised: Caregiver—Follow-Up (CIQ–RC–F)

CHILD ID:

[NOTE TO INTERVIEWER: Questions #16, #16a, and #17 are skipped, as they are not applicable at
follow-up.]
17a. In the past 6 months, has (child’s name) run away without his/her caregiver knowing where
he/she was?
[NOTE TO INTERVIEWER: This could be the current caregiver or a past caregiver.]
1 = No
2 = Yes
[NOTE TO INTERVIEWER: Question #18 is skipped, as it is not applicable at follow-up.]
18a. In the past 6 months, has (child’s name) had a problem with substance abuse, including
alcohol and drugs?
1 = No
2 = Yes
[NOTE TO INTERVIEWER: Question #19 is skipped, as it is not applicable at follow-up.]
19a. In the past 6 months, has (child’s name) talked about committing suicide?
1 = No
2 = Yes
[NOTE TO INTERVIEWER: Questions #20 and #20a are skipped, as they are not applicable at followup.]
20b. In the past 6 months, has (child’s name) attempted suicide?
1 = No [GO TO QUESTION #21a]
2 = Yes
20c. In the past 6 months, how many times has (child’s name) attempted suicide?
_____ times
Now I need to ask some questions concerning (child’s name)’s family and household history. These
questions are about (child’s name)’s biological family and the people who live, or lived, in (child’s
name)’s household. For these questions, when you think about (child’s name)’s households, do not
include residential treatment centers or group homes in which (child’s name) may have lived.
[NOTE TO INTERVIEWER: Question #21 is skipped, as it is not applicable at follow-up.]
21a. In the past 6 months, has (child’s name) been exposed to domestic violence or spousal abuse,
of which (child’s name) was not the direct target?
1 = No
2 = Yes
For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
6

Caregiver Information Questionnaire,
Revised: Caregiver—Follow-Up (CIQ–RC–F)

CHILD ID:

22.

Has anyone in (child’s name)’s biological family ever been diagnosed with depression or shown
signs of depression? By biological family, I mean (child’s name)’s biological parents,
grandparents, and siblings.
1 = No
2 = Yes

[NOTE TO INTERVIEWER: Question #22a is skipped, as it is not applicable at follow-up.]
22b. In the past 6 months, has (child’s name) lived in a household in which one of the household
members showed signs of being depressed?
1 = No [GO TO QUESTION #23]
2 = Yes
22c. Was the person who showed signs of being depressed involved in providing care and
supervision to (child’s name)?
1 = No
2 = Yes
23.

Has anyone in (child’s name)’s biological family had a mental illness, other than depression? By
biological family, I mean (child’s name)’s biological parents, grandparents, and siblings.
1 = No
2 = Yes

[NOTE TO INTERVIEWER: Question #23a is skipped, as it is not applicable at follow-up.]
23b. In the past 6 months, has (child’s name) lived in a household in which one of the household
members had a mental illness other than depression?
1 = No [GO TO QUESTION #24a]
2 = Yes
23c. Was the person with a mental illness involved in providing care and supervision to (child’s
name)?
1 = No
2 = Yes
[NOTE TO INTERVIEWER: Question #24 is skipped, as it is not applicable at follow-up.]
24a. In the past 6 months, have any members of (child’s name)’s household been convicted of a
crime?
1 = No
2 = Yes

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
7

Caregiver Information Questionnaire,
Revised: Caregiver—Follow-Up (CIQ–RC–F)

CHILD ID:

25.

Has anyone in (child’s name)’s biological family had a drinking or drug problem? By biological
family, I mean (child’s name)’s biological parents, grandparents, and siblings.
1 = No
2 = Yes

[NOTE TO INTERVIEWER: Question #25a is skipped, as it is not applicable at follow-up.]
25b. In the past 6 months, has (child’s name) lived in a household in which one of the household
members had a drinking or drug problem?
1 = No [GO TO QUESTION #31]
2 = Yes
25c. Was the person with a drinking or drug problem involved in providing care and supervision
to (child’s name)?
1 = No
2 = Yes
[NOTE TO INTERVIEWER: Questions #26–30 are skipped, as they are not applicable at follow-up.]
Now I’m going to ask you some questions related to (child’s name)’s health.
31.

Does (child’s name) have recurring or chronic physical health problems such as allergies, asthma,
migraine headaches, diabetes, epilepsy, cancer, etc.?
1 = No [GO TO QUESTION #33]
2 = Yes

32.

What recurring or chronic physical health problems does (child’s name) have? [Select all that
apply]
1 = Allergies
2 = Asthma
3 = Cancer
4 = Cerebral palsy
5 = Diabetes
6 = Epilepsy
7 = Migraine headaches
8 = Heart condition
9 = High blood pressure
10 = Overweight
11 = Sickle cell anemia
12 = Spina bifida
13 = Thyroid problems
14 = Other—please specify ____________________________________________
32a. Now or in the past 6 months, has (child’s name) taken medication related to his/her (name of
child’s physical health problems)?
1 = No
2 = Yes

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
8

Caregiver Information Questionnaire,
Revised: Caregiver—Follow-Up (CIQ–RC–F)

CHILD ID:

32b. During the past 6 months, have the regular activities (child’s name) participates in (such as
school, social activities, participation in treatment for emotional or behavioral problems,
etc.) been disrupted because of problems related to his/her recurring or chronic physical
health problems?
1 = No
2 = Yes
33.

In the past 6 months, how many times did (child’s name) see a doctor or other primary health care
provider for a physical health problem, not during an emergency room visit?
_____ times [RECORD 0, IF NONE]

34.

During the past 6 months, how many times did (child’s name) have to go to the emergency room to
seek treatment for a physical health problem?
_____ times [RECORD 0, IF NONE]
34a. During the past 6 months, how many times did (child’s name) have to go to the emergency
room to seek treatment as a result of his/her behavioral or emotional problem?
_____ times [RECORD 0, IF NONE]

35.

During the past 6 months, how many times was (child’s name) hospitalized for a physical health
problem?
_____ times [RECORD 0, IF NONE]
35a. [IF 1 OR MORE] What is the total number of days that (child’s name) was hospitalized for a
physical problem in the past 6 months?
_____ days

36.

Has (child’s name) had a routine physical health exam in the past 6 months?
1 = No
2 = Yes

[NOTE TO INTERVIEWER: Questions #37 and #37a are skipped, as they are not applicable at followup.]
38.

Do you, or any other member of your household other than (child’s name), have recurring or
chronic physical health problems such as allergies, asthma, migraine headaches, diabetes, epilepsy,
cancer, etc.?
1 = No [GO TO QUESTION #39]
2 = Yes

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
9

Caregiver Information Questionnaire,
Revised: Caregiver—Follow-Up (CIQ–RC–F)

CHILD ID:

[CARD 5]
38a. In the past 6 months, how much has your ability to care for (child’s name) been affected by
the chronic health problems of these household members?
1 = Not at all
2 = A little bit
3 = A moderate amount
4 = Quite a bit
5 = A great deal
Sometimes a doctor or psychiatrist prescribes medication for children to help reduce their emotional or
behavioral symptoms. For example, Adderall may be prescribed for Attention-Deficit Disorder.
39.

Now or in the past 6 months, has (child’s name) taken any medication related to his/her emotional
or behavioral symptoms?
1 = No [GO TO QUESTION #40]
2 = Yes

[CARD 6]
39a. Who prescribed these medications 39b. In the past 6 months, how many times did
for (child’s name)? [Select all that
you/(child’s name) see this doctor for follow-up on
these prescribed medications?
apply]
More
than 6
times

Not at
all

1 time

2 times

1 = Primary care physician/family
physician

1

2

3

4

5

6

2 = Child psychiatrist

1

2

3

4

5

6

3 = General psychiatrist

1

2

3

4

5

6

4 = Pediatrician

1

2

3

4

5

6

1

2

3

4

5

6

1

2

3

4

5

6

3–5 times 6 times

5 = Other—please specify
________________________
6 = Other—please specify
________________________

[NOTE TO INTERVIEWER: Do not read the medications in the medication table to the caregiver. Record
the caregiver’s response and then circle the appropriate responses in the table.]
39c. [IF YES TO #39] Please tell me the medication(s) that (child’s name) is currently taking or
has taken in the past 6 months.
__________________________________________________________________________

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
10

Caregiver Information Questionnaire,
Revised: Caregiver—Follow-Up (CIQ–RC–F)

CHILD ID:

[Select all that apply]
Taking currently or
in the past 6 months
Medication Category

No

Yes

Abilify (aripiprazole)

1

2

Adderall (amphetamine mixed salts)

1

2

Catapres (clonidine)

1

2

Celexa (citalopram)

1

2

Concerta (methylphenidate)

1

2

Daytrana (methylphenidate transdermal system)

1

2

Depakote (valproic acid and derivatives)

1

2

Desyrel (trazodone)

1

2

Dexedrine (dextroamphetamine)

1

2

Effexor (venlafaxine)

1

2

Eskalith (lithium)

1

2

Focalin (dexmethylphenidate)

1

2

Geodon (ziprasidone)

1

2

Haldol (haloperidol)

1

2

Klonopin (clonazepam)

1

2

Lamictal (lamotrigine)

1

2

Lexapro (escitalopram)

1

2

Lithobid (lithium)

1

2

Lithonate (lithium)

1

2

Metadate (methylphenidate)

1

2

Neurontin (gabapentin)

1

2

Orap (pimozide)

1

2

Paxil (paroxetine)

1

2

Prozac (fluoxetine)

1

2

Remeron (mirtazapine)

1

2

Risperdal (risperidone)

1

2

Ritalin (methylphenidate)

1

2

Seroquel (quetiapine)

1

2

Strattera (atomoxetine)

1

2

Symbyax (olanzapine and fluoxetine)

1

2

Tegretol (carbamazepine)

1

2

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
11

Caregiver Information Questionnaire,
Revised: Caregiver—Follow-Up (CIQ–RC–F)

CHILD ID:

Taking currently or
in the past 6 months
Medication Category

No

Yes

Tenex (guanfacine)

1

2

Topamax (topiramate)

1

2

Trileptal (oxcarbazepine)

1

2

Vyvanse (lisdexamfetamine dimesylate)

1

2

Wellbutrin (bupropion)

1

2

Xanax (alprazolam)

1

2

Zoloft (sertraline)

1

2

Zyprexa (olanzapine)

1

2

Other—please specify __________________________

1

2

I will now read you several statements. These statements are about any medications that (child’s name) is
currently taking, or has taken in the past 6 months, for his/her emotional or behavioral symptoms. For
each of the statements, please tell me how strongly you agree that the statement reflects your experience.

[CARD 7]
Strongly
Strongly
disagree Disagree Undecided Agree
agree
39d. I see benefits from (child’s name) taking
his/her medication.

1

2

3

4

5

39e. I understand why (child’s name) takes
his/her medication.

1

2

3

4

5

39f. I know what (child’s name)’s medication
is supposed to do for him/her.

1

2

3

4

5

39g. I had a choice in the medication that
(child’s name) takes.

1

2

3

4

5

39h. (Child’s name) takes his/her medication
the way he/she is supposed to.

1

2

3

4

5

39i. I feel comfortable about (child’s name)
taking medication.

1

2

3

4

5

Now I am going to ask you some questions about your family and about peer support that you may be
receiving from a family advocate, parent partner, or family liaison. This type of support is typically
received from another family member who is trained to work with families.
40.

Do you have a family advocate/parent partner/family liaison/other name?
1 = No [GO TO QUESTION #45]
2 = Yes

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
12

Caregiver Information Questionnaire,
Revised: Caregiver—Follow-Up (CIQ–RC–F)

CHILD ID:

[CARD 8]
41.

In the past 6 months, how often did you meet with your (title of family advocate)?
1 = Never
2 = Not very often
3 = Sometimes
4 = Often
5 = Very often
No

42.

Yes

In the past 6 months, did the (title of family advocate) participate or assist you in any of the
following activities:
42a. Assistance with finances (e.g., budgeting, obtaining flex funds)

1

2

42b. Assistance with transportation

1

2

42c. Assistance with obtaining basic needs (e.g., housing, clothes, food)

1

2

42d. Dealing with agencies or getting services (e.g., child welfare, court,
schools/IEP, medical care, legal assistance)

1

2

42e. Obtaining employment or education services for you (e.g., resume
assistance, job training)

1

2

42f. Obtaining employment or education services for your child

1

2

42g. Provided you with social or emotional support

1

2

42h. Parenting skills/assistance

1

2

42i. Other—please specify _____________________________________

1

2

[CARD 9]
43.

In the past 6 months, how well did the (title of family advocate) address the issues brought to
his/her attention?
1 = Not at all well
2 = Somewhat well
3 = Moderately well
4 = Very well
5 = Extremely well

[CARD 10]
44.

In the past 6 months, how available was your (title of family advocate) when you needed him/her?
1 = Not at all
2 = Somewhat
3 = Moderately
4 = Very much
5 = Extremely

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
13

Caregiver Information Questionnaire,
Revised: Caregiver—Follow-Up (CIQ–RC–F)

CHILD ID:

[CARD 8]
45.

In the past 6 months, how often did your family do things together outside of your home?
1 = Never
2 = Not very often
3 = Sometimes
4 = Often
5 = Very often

46.

In the past 6 months, how often did your family spend time together as a family?
1 = Never
2 = Not very often
3 = Sometimes
4 = Often
5 = Very often

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
14

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 17 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

CAREGIVER INFORMATION QUESTIONNAIRE,
Revised: Staff as Caregiver—Intake (CIQ–RS–I)
/

CIQDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

1 = Intake

CIQRESP (Respondent for interview)

2 = Staff as Caregiver (staffperson who has acted as the
child’s day-to-day caregiver for the majority of the past 6
months)

CIQINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

CIQMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

CIQLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Date last modified: September 2012

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Intake (CIQ–RS–I)

CHILD ID:

I am going to ask you some questions about (child’s name)’s background and family and about services
that (child’s name) has received. Please answer these questions as best you can, and try to be as complete
as possible in your answers. To begin, I’d like to ask a couple of questions about you, and then I’ll ask
you a few general questions about (child’s name)’s background and family.
[NOTE TO INTERVIEWER: Question #1 is skipped for “staff as caregiver,” as it is not applicable for
this respondent.]
1a.

What is your gender?
1 = Male
2 = Female

2.

What is your age?
_____ years

3.

Are you of Hispanic or Latino cultural/ethnic background?
1 = No [GO TO QUESTION #4]
2 = Yes
3a.

Which group(s) describes your Hispanic or Latino cultural/ethnic background? Are you . . .
[Select one or more]
1 = Mexican, Mexican American, or Chicano
2 = Puerto Rican
3 = Cuban
4 = Dominican
5 = Central American
6 = South American
7 = Other—please specify __________________________

4.

Which group(s) describes you? Are you . . . [Select one or more]
1 = American Indian or Alaska Native
2 = Asian
3 = Black or African American
4 = Native Hawaiian or Other Pacific Islander
5 = White
[NOTE TO INTERVIEWER: Do not ask if there is another group that describes the respondent. If
the respondent is unable to select from options 1–5 and he/she provides an alternate group, record
that answer on the line by option 6.]
6 = Other—please specify __________________________

[NOTE TO INTERVIEWER: For Questions #5 and #5c, do not read the response options to the
respondent.]
5.

What language or languages does (child’s name) speak? [Select all that apply]
1 = English
2 = Spanish
3 = Other—please specify __________________________

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
1

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Intake (CIQ–RS–I)

CHILD ID:

[NOTE TO INTERVIEWER: Questions #5a and #5b are skipped for “staff as caregiver,” as they are not
applicable for this respondent.]
5c.

Which is (child’s name)’s most preferred language?
1 = English
2 = Spanish
3 = Other—please specify __________________________

6.

What is the highest level of education that (child’s name)’s primary family caregiver has
completed?
_____
[IF FROM KINDERGARTEN TO 11TH GRADE, enter 0–11] 0–11 = Kindergarten–11th grade
[IF FINISHED HIGH SCHOOL, select the appropriate category below]
12 = High school diploma or GED
13 = Associate degree
14 = Some college, no degree
15 = Bachelor’s degree
16 = Master’s degree
17 = Professional school degree
18 = Doctoral degree

7.

Other than a primary caregiver, does (child’s name) currently have a close relationship with an adult
who provides advice and support?
1 = No
2 = Yes

8.

Who has legal custody of (child’s name)?
1 = Two biological parents or one biological and one step or adoptive parent
2 = Biological mother only
3 = Biological father only
4 = Adoptive parent(s)
5 = Sibling(s)
6 = Aunt and/or uncle
7 = Grandparent(s)
8 = Friend (adult friend)
9 = Ward of the State
10 = Other—please specify __________________________

[NOTE TO INTERVIEWER: Questions #9 and #10 are skipped for “staff as caregiver,” as they are not
applicable for this respondent.]
11.

For approximately how many days in the past 6 months did you interact with (child’s name) on a
daily basis?
_____ days [6 months = 180 days]

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
2

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Intake (CIQ–RS–I)

CHILD ID:

[CARD 1]
12.

What is the annual household income of (child’s name)’s family?
For this question, (child’s name)’s family should be considered to be the family with whom he/she
has lived for the majority of the past 6 months. For example, if (child’s name) has lived with a
foster family for most of the past 6 months, we are interested in knowing the foster family’s income.
[NOTE TO INTERVIEWER: Prompt respondent to consider all sources of pre-tax (gross) income,
including wages, child support, alimony, and public assistance. The family household income
should include the pre-tax incomes of all individuals who live with the child and contribute
financially to the child’s care.]
1 = Less than $5,000
2 = $5,000–$9,999
3 = $10,000–$14,999
4 = $15,000–$19,999
5 = $20,000–$24,999
6 = $25,000–$34,999
7 = $35,000–$49,999
8 = $50,000–$74,999
9 = $75,000–$99,999
10 = $100,000 and over

[NOTE TO INTERVIEWER: Questions #13 and #14 are skipped for “staff as caregiver,” as they are not
applicable for this respondent.]
Now I need to ask some questions concerning (child’s name)’s history.
15.

Has (child’s name) ever experienced or witnessed an event that caused, or threatened to cause,
serious harm to him or herself or to someone else? [Select all that apply]
1 = Car accident
2 = Other accident
3 = Fire
4 = Storm
5 = Physical illness
6 = Physical assault
7 = Sexual assault
8 = Any other event—please specify __________________________
9 = Has not experienced or witnessed a traumatic event [GO TO QUESTION #17]

I’m going to read to you a list of behaviors that describe children. After I read each behavior, tell me
which description best describes (child’s name) now or within the past 6 months. Rate each statement by
the following criteria: the statement is very true or often true, somewhat or sometimes true, or not true of
(child’s name). Please answer all items as well as you can even if some do not seem to apply to (child’s
name). The term “event” refers to the most stressful experience that you have described above.

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
3

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Intake (CIQ–RS–I)

CHILD ID:

[CARD 2]

16.

Not
true

Somewhat or
sometimes
true

Very true
or often
true

15a. Child gets very upset if reminded of the event.

0

1

2

15b. Child reports more physical complaints when reminded
of the event. For example, headaches, stomachaches,
nausea, difficulty breathing.

0

1

2

15c. Child reports that he or she does not want to talk about
the event.

0

1

2

15d. Child startles easily. For example, he or she jumps when
hears sudden or loud noises.

0

1

2

[If Physical assault selected in #15] In the past 6 months, has (child’s name) been physically
abused?
1 = No
2 = Yes
16a. [If Sexual assault selected in #15] In the past 6 months, has (child’s name) been sexually
abused?
1 = No
2 = Yes

17.

Has (child’s name) ever run away without his/her caregiver knowing where he/she was?
[NOTE TO INTERVIEWER: This could be the current caregiver or a past caregiver.]
1 = No [GO TO QUESTION #18]
2 = Yes
17a. In the past 6 months, has (child’s name) run away without his/her caregiver knowing where
he/she was?
[NOTE TO INTERVIEWER: This could be the current caregiver or a past caregiver.]
1 = No
2 = Yes

18.

Has (child’s name) ever had a problem with substance abuse, including alcohol and/or drugs?
1 = No [GO TO QUESTION #19]
2 = Yes
18a. In the past 6 months, has (child’s name) had a problem with substance abuse, including
alcohol and drugs?
1 = No
2 = Yes

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
4

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Intake (CIQ–RS–I)

CHILD ID:

19.

Has (child’s name) ever talked about committing suicide?
1 = No [GO TO QUESTION #20]
2 = Yes
19a. In the past 6 months, has (child’s name) talked about committing suicide?
1 = No
2 = Yes

20.

Has (child’s name) ever attempted suicide?
1 = No [GO TO QUESTION #21]
2 = Yes
20a. How many times has (child’s name) attempted suicide?
_____ times
20b. In the past 6 months, has (child’s name) attempted suicide?
1 = No [GO TO QUESTION #21]
2 = Yes
20c. In the past 6 months, how many times has (child’s name) attempted suicide?
_____ times

Now I need to ask some questions concerning (child’s name)’s family and household history. These
questions are about (child’s name)’s biological family and the people who live, or lived, in (child’s
name)’s household. For these questions, when you think about (child’s name)’s households, do not
include residential treatment centers or group homes in which (child’s name) may have lived.
21.

Has (child’s name) ever been exposed to domestic violence or spousal abuse, of which (child’s
name) was not the direct target?
1 = No [GO TO QUESTION #22]
2 = Yes
21a. In the past 6 months, has (child’s name) been exposed to domestic violence or spousal abuse,
of which (child’s name) was not the direct target?
1 = No
2 = Yes

22.

Has anyone in (child’s name)’s biological family ever been diagnosed with depression or shown
signs of depression? By biological family, I mean (child’s name)’s biological parents,
grandparents, and siblings.
1 = No
2 = Yes
22a. Has (child’s name) ever lived in a household in which someone showed signs of being
depressed?
1 = No [GO TO QUESTION #23]
2 = Yes

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
5

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Intake (CIQ–RS–I)

CHILD ID:

22b. In the past 6 months, has (child’s name) lived in a household in which one of the household
members showed signs of being depressed?
1 = No [GO TO QUESTION #23]
2 = Yes
22c. Was the person who showed signs of being depressed involved in providing care and
supervision to (child’s name)?
1 = No
2 = Yes
23.

Has anyone in (child’s name)’s biological family had a mental illness, other than depression? By
biological family, I mean (child’s name)’s biological parents, grandparents, and siblings.
1 = No
2 = Yes
23a. Other than depression, has (child’s name) ever lived in a household in which someone had a
mental illness?
1 = No [GO TO QUESTION #24]
2 = Yes
23b. In the past 6 months, has (child’s name) lived in a household in which one of the household
members had a mental illness other than depression?
1 = No [GO TO QUESTION #24]
2 = Yes
23c. Was the person with a mental illness involved in providing care and supervision to (child’s
name)?
1 = No
2 = Yes

24.

Has (child’s name) ever lived in a household in which someone had been convicted of a crime?
1 = No [GO TO QUESTION #25]
2 = Yes
24a. In the past 6 months, have any members of (child’s name)’s household been convicted of a
crime?
1 = No
2 = Yes

25.

Has anyone in (child’s name)’s biological family had a drinking or drug problem? By biological
family, I mean (child’s name)’s biological parents, grandparents, and siblings.
1 = No
2 = Yes
25a. Has (child’s name) ever lived in a household in which one of the household members had a
drinking or drug problem?
1 = No [GO TO QUESTION #31]
2 = Yes

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
6

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Intake (CIQ–RS–I)

CHILD ID:

25b. In the past 6 months, has (child’s name) lived in a household in which one of the household
members had a drinking or drug problem?
1 = No [GO TO QUESTION #31]
2 = Yes
25c. Was the person with a drinking or drug problem involved in providing care and supervision
to (child’s name)?
1 = No
2 = Yes
[NOTE TO INTERVIEWER: Questions #26–30 are skipped for “staff as caregiver,” as they are not
applicable for this respondent.]
Now I’m going to ask you some questions related to (child’s name)’s health.
31.

Does (child’s name) have recurring or chronic physical health problems such as allergies, asthma,
migraine headaches, diabetes, epilepsy, cancer, etc.?
1 = No [GO TO QUESTION #33]
2 = Yes

32.

What recurring or chronic physical health problems does (child’s name) have? [Select all that
apply]
1 = Allergies
2 = Asthma
3 = Cancer
4 = Cerebral palsy
5 = Diabetes
6 = Epilepsy
7 = Migraine headaches
8 = Heart condition
9 = High blood pressure
10 = Overweight
11 = Sickle cell anemia
12 = Spina bifida
13 = Thyroid problems
14 = Other—please specify ____________________________________________
32a. Now or in the past 6 months, has (child’s name) taken medication related to his/her (name of
child’s physical health problems)?
1 = No
2 = Yes
32b. During the past 6 months, have the regular activities (child’s name) participates in (such as
school, social activities, participation in treatment for emotional or behavioral problems,
etc.) been disrupted because of problems related to his/her recurring or chronic physical
health problems?
1 = No
2 = Yes

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
7

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Intake (CIQ–RS–I)

CHILD ID:

33.

In the past 6 months, how many times did (child’s name) see a doctor or other primary health care
provider for a physical health problem, not during an emergency room visit?
_____ times [RECORD 0, IF NONE]

34.

During the past 6 months, how many times did (child’s name) have to go to the emergency room to
seek treatment for a physical health problem?
_____ times [RECORD 0, IF NONE]
34a. During the past 6 months, how many times did (child’s name) have to go to the emergency
room to seek treatment as a result of his/her behavioral or emotional problem?
_____ times [RECORD 0, IF NONE]

35.

During the past 6 months, how many times was (child’s name) hospitalized for a physical health
problem?
_____ times [RECORD 0, IF NONE]
35a. [IF 1 OR MORE] What is the total number of days that (child’s name) was hospitalized for a
physical problem in the past 6 months?
_____ days

36.

Has (child’s name) had a routine physical health exam in the past 6 months?
1 = No
2 = Yes

37.

Does (child’s name) have a primary health care provider?
1 = No [GO TO QUESTION #38]
2 = Yes
37a. What type of provider is (child’s name)’s primary health care provider?
1 = Pediatrician
2 = Physician other than a pediatrician
3 = Physician’s assistant
4 = Nurse practitioner
5 = No consistent primary health care provider
6 = Tribal healer/alternative health practitioner
7 = Other—please specify ____________________________________________

38.

Do any members of (child’s name)’s family have recurring or chronic physical health problems
such as allergies, asthma, migraine headaches, diabetes, epilepsy, cancer, etc.?
1 = No [GO TO QUESTION #39]
2 = Yes

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
8

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Intake (CIQ–RS–I)

CHILD ID:

[CARD 3]
38a. In the past 6 months, how much has (child’s name)’s family’s ability to care for him/her been
affected by the chronic health problems of these family members?
1 = Not at all
2 = A little bit
3 = A moderate amount
4 = Quite a bit
5 = A great deal
Sometimes a doctor or psychiatrist prescribes medication for children to help reduce their emotional or
behavioral symptoms. For example, Adderall may be prescribed for Attention-Deficit Disorder.
39.

Now or in the past 6 months, has (child’s name) taken any medication related to his/her emotional
or behavioral symptoms?
1 = No [END OF QUESTIONNAIRE]
2 = Yes

[CARD 4]
39a. Who prescribed these medications 39b. In the past 6 months, how many times did (child’s
for (child’s name)? [Select all that
name) see this doctor for follow-up on these
prescribed medications?
apply]
More
than 6
times

Not at
all

1 time

2 times

1 = Primary care physician/family
physician

1

2

3

4

5

6

2 = Child psychiatrist

1

2

3

4

5

6

3 = General psychiatrist

1

2

3

4

5

6

4 = Pediatrician

1

2

3

4

5

6

1

2

3

4

5

6

1

2

3

4

5

6

3–5 times 6 times

5 = Other—please specify
________________________
6 = Other—please specify
________________________

[NOTE TO INTERVIEWER: Do not read the medications in the medication table to the caregiver. Record
the caregiver’s response and then circle the appropriate responses in the table.]
39c. [IF YES TO #39] Please tell me the medication(s) that (child’s name) is currently taking or
has taken in the past 6 months.
__________________________________________________________________________

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
9

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Intake (CIQ–RS–I)

CHILD ID:

[Select all that apply]
Taking currently or
in the past 6 months
Medication Category

No

Yes

Abilify (aripiprazole)

1

2

Adderall (amphetamine mixed salts)

1

2

Catapres (clonidine)

1

2

Celexa (citalopram)

1

2

Concerta (methylphenidate)

1

2

Daytrana (methylphenidate transdermal system)

1

2

Depakote (valproic acid and derivatives)

1

2

Desyrel (trazodone)

1

2

Dexedrine (dextroamphetamine)

1

2

Effexor (venlafaxine)

1

2

Eskalith (lithium)

1

2

Focalin (dexmethylphenidate)

1

2

Geodon (ziprasidone)

1

2

Haldol (haloperidol)

1

2

Klonopin (clonazepam)

1

2

Lamictal (lamotrigine)

1

2

Lexapro (escitalopram)

1

2

Lithobid (lithium)

1

2

Lithonate (lithium)

1

2

Metadate (methylphenidate)

1

2

Neurontin (gabapentin)

1

2

Orap (pimozide)

1

2

Paxil (paroxetine)

1

2

Prozac (fluoxetine)

1

2

Remeron (mirtazapine)

1

2

Risperdal (risperidone)

1

2

Ritalin (methylphenidate)

1

2

Seroquel (quetiapine)

1

2

Strattera (atomoxetine)

1

2

Symbyax (olanzapine and fluoxetine)

1

2

Tegretol (carbamazepine)

1

2

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
10

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Intake (CIQ–RS–I)

CHILD ID:

Taking currently or
in the past 6 months
Medication Category

No

Yes

Tenex (guanfacine)

1

2

Topamax (topiramate)

1

2

Trileptal (oxcarbazepine)

1

2

Vyvanse (lisdexamfetamine dimesylate)

1

2

Wellbutrin (bupropion)

1

2

Xanax (alprazolam)

1

2

Zoloft (sertraline)

1

2

Zyprexa (olanzapine)

1

2

Other—please specify __________________________

1

2

[NOTE TO INTERVIEWER: Questions #39d–g and #39i are skipped for “staff as caregiver,” as they are
not applicable for this respondent.]
I will now read you a statement about any medications that (child’s name) is currently taking, or has taken
in the past 6 months, for his/her emotional or behavioral symptoms. Please tell me how strongly you
agree that the statement reflects your experience.

[CARD 5]
Strongly
Strongly
disagree Disagree Undecided Agree
agree
39h. (Child’s name) takes his/her medication
the way he/she is supposed to.

1

2

3

4

5

[NOTE TO INTERVIEWER: Questions #40–46 are skipped for “staff as caregiver,” as they are not
applicable for this respondent.]

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
11

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 12 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

CAREGIVER INFORMATION QUESTIONNAIRE,
Revised: Staff as Caregiver—Follow-Up
(CIQ–RS–F)
/

CIQDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

CIQRESP (Respondent for interview)

2 = Staff as Caregiver (staffperson who has acted as the
child’s day-to-day caregiver for the majority of the past 6
months)

CIQINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

CIQMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

CIQLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Date last modified: September 2012

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Follow-Up (CIQ–RS–F)

CHILD ID:

I am going to ask you some questions about (child’s name)’s background and family and about services
that (child’s name) has received. Please answer these questions as best you can, and try to be as complete
as possible in your answers.
0.

Have you ever answered questions about (child’s name) and his/her family for this study before?
1 = No [GO TO QUESTION #1]
2 = Yes

[CARD 1]
0a.

When did you answer these questions?

[NOTE TO INTERVIEWER: Circle all that apply. To prompt the respondent, identify the actual
time period for each of the answer choices. For example, “About 6 months ago would have been
March 15.”]
1 = About 6 months ago
2 = About 12 months ago
3 = About 18 months ago
4 = About 24 months ago
5 = Other—please specify __________________________
[GO TO QUESTION #6]
To begin, I’d like to ask a couple of questions about you, and then I’ll ask you a few general questions
about (child’s name)’s background and family.
[NOTE TO INTERVIEWER: Question #1 is skipped for “staff as caregiver,” as it is not applicable for
this respondent.]
1a.

What is your gender?
1 = Male
2 = Female

2.

What is your age?
_____ years

3.

Are you of Hispanic or Latino cultural/ethnic background?
1 = No [GO TO QUESTION #4]
2 = Yes
3a.

Which group(s) describes your Hispanic or Latino cultural/ethnic background? Are you . . .
[Select one or more]
1 = Mexican, Mexican American, or Chicano
2 = Puerto Rican
3 = Cuban
4 = Dominican
5 = Central American
6 = South American
7 = Other—please specify __________________________

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
1

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Follow-Up (CIQ–RS–F)

CHILD ID:

4.

Which group(s) describes you? Are you . . . [Select one or more]
1 = American Indian or Alaska Native
2 = Asian
3 = Black or African American
4 = Native Hawaiian or Other Pacific Islander
5 = White
[NOTE TO INTERVIEWER: Do not ask if there is another group that describes the respondent. If
the respondent is unable to select from options 1–5 and he/she provides an alternate group, record
that answer on the line by option 6.]
6 = Other—please specify __________________________

[NOTE TO INTERVIEWER: Questions #5–5c are skipped for “staff as caregiver,” as they are not
applicable for this respondent.]
6.

What is the highest level of education that (child’s name)’s primary family caregiver has
completed?
_____
[IF FROM KINDERGARTEN TO 11TH GRADE, enter 0–11] 0–11 = Kindergarten–11th grade
[IF FINISHED HIGH SCHOOL, select the appropriate category below]
12 = High school diploma or GED
13 = Associate degree
14 = Some college, no degree
15 = Bachelor’s degree
16 = Master’s degree
17 = Professional school degree
18 = Doctoral degree

7.

Other than a primary caregiver, does (child’s name) currently have a close relationship with an adult
who provides advice and support?
1 = No
2 = Yes

8.

Who has legal custody of (child’s name)?
1 = Two biological parents or one biological and one step or adoptive parent
2 = Biological mother only
3 = Biological father only
4 = Adoptive parent(s)
5 = Sibling(s)
6 = Aunt and/or uncle
7 = Grandparent(s)
8 = Friend (adult friend)
9 = Ward of the State
10 = Other—please specify __________________________

[NOTE TO INTERVIEWER: Questions #9 and #10 are skipped for “staff as caregiver,” as they are not
applicable for this respondent.]
For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
2

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Follow-Up (CIQ–RS–F)

CHILD ID:

11.

For approximately how many days in the past 6 months did you interact with (child’s name) on a
daily basis?
_____ days [6 months = 180 days]

[CARD 2]
12.

What is the annual household income of (child’s name)’s family?
For this question, (child’s name)’s family should be considered to be the family with whom he/she
has lived for the majority of the past 6 months. For example, if (child’s name) has lived with a
foster family for most of the past 6 months, we are interested in knowing the foster family’s income.
[NOTE TO INTERVIEWER: Prompt respondent to consider all sources of pre-tax (gross) income,
including wages, child support, alimony, and public assistance. The family household income
should include the pre-tax incomes of all individuals who live with the child and contribute
financially to the child’s care.]
1 = Less than $5,000
2 = $5,000–$9,999
3 = $10,000–$14,999
4 = $15,000–$19,999
5 = $20,000–$24,999
6 = $25,000–$34,999
7 = $35,000–$49,999
8 = $50,000–$74,999
9 = $75,000–$99,999
10 = $100,000 and over

[NOTE TO INTERVIEWER: Questions #13 and #14 are skipped for “staff as caregiver,” as they are not
applicable for this respondent.]
Now I need to ask some questions concerning (child’s name)’s history.
15.

In the past 6 months, has (child’s name) experienced or witnessed an event that caused, or
threatened to cause, serious harm to him or herself or to someone else? [Select all that apply]
1 = Car accident
2 = Other accident
3 = Fire
4 = Storm
5 = Physical illness
6 = Physical assault
7 = Sexual assault
8 = Any other event—please specify __________________________
9 = Has not experienced or witnessed a traumatic event [GO TO QUESTION #17a]

I’m going to read to you a list of behaviors that describe children. After I read each behavior, tell me
which description best describes (child’s name) now or within the past 6 months. Rate each statement by
the following criteria: the statement is very true or often true, somewhat or sometimes true, or not true of
(child’s name). Please answer all items as well as you can even if some do not seem to apply to (child’s
name). The term “event” refers to the most stressful experience that you have described above.
For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
3

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Follow-Up (CIQ–RS–F)

CHILD ID:

[CARD 3]
Not
true

Somewhat or
sometimes
true

Very true
or often
true

15a. Child gets very upset if reminded of the event.

0

1

2

15b. Child reports more physical complaints when reminded
of the event. For example, headaches, stomachaches,
nausea, difficulty breathing.

0

1

2

15c. Child reports that he or she does not want to talk about
the event.

0

1

2

15d. Child startles easily. For example, he or she jumps when
hears sudden or loud noises.

0

1

2

[NOTE TO INTERVIEWER: Questions #16, #16a, and #17 are skipped, as they are not applicable at
follow-up.]
17a. In the past 6 months, has (child’s name) run away without his/her caregiver knowing where
he/she was?
[NOTE TO INTERVIEWER: This could be the current caregiver or a past caregiver.]
1 = No
2 = Yes
[NOTE TO INTERVIEWER: Question #18 is skipped, as it is not applicable at follow-up.]
18a. In the past 6 months, has (child’s name) had a problem with substance abuse, including
alcohol and drugs?
1 = No
2 = Yes
[NOTE TO INTERVIEWER: Question #19 is skipped, as it is not applicable at follow-up.]
19a. In the past 6 months, has (child’s name) talked about committing suicide?
1 = No
2 = Yes
[NOTE TO INTERVIEWER: Questions #20 and #20a are skipped, as they are not applicable at followup.]
20b. In the past 6 months, has (child’s name) attempted suicide?
1 = No [GO TO QUESTION #21a]
2 = Yes

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
4

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Follow-Up (CIQ–RS–F)

CHILD ID:

20c. In the past 6 months, how many times has (child’s name) attempted suicide?
_____ times

Now I need to ask some questions concerning (child’s name)’s family and household history. These
questions are about (child’s name)’s biological family and the people who live, or lived, in (child’s
name)’s household. For these questions, when you think about (child’s name)’s households, do not
include residential treatment centers or group homes in which (child’s name) may have lived.
[NOTE TO INTERVIEWER: Question #21 is skipped, as it is not applicable at follow-up.]
21a. In the past 6 months, has (child’s name) been exposed to domestic violence or spousal abuse,
of which (child’s name) was not the direct target?
1 = No
2 = Yes
22.

Has anyone in (child’s name)’s biological family ever been diagnosed with depression or shown
signs of depression? By biological family, I mean (child’s name)’s biological parents,
grandparents, and siblings.
1 = No
2 = Yes

[NOTE TO INTERVIEWER: Question #22a is skipped, as it is not applicable at follow-up.]
22b. In the past 6 months, has (child’s name) lived in a household in which one of the household
members showed signs of being depressed?
1 = No [GO TO QUESTION #23]
2 = Yes
22c. Was the person who showed signs of being depressed involved in providing care and
supervision to (child’s name)?
1 = No
2 = Yes
23.

Has anyone in (child’s name)’s biological family had a mental illness, other than depression? By
biological family, I mean (child’s name)’s biological parents, grandparents, and siblings.
1 = No
2 = Yes

[NOTE TO INTERVIEWER: Question #23a is skipped, as it is not applicable at follow-up.]
23b. In the past 6 months, has (child’s name) lived in a household in which one of the household
members had a mental illness other than depression?
1 = No [GO TO QUESTION #24a]
2 = Yes
For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
5

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Follow-Up (CIQ–RS–F)

CHILD ID:

23c. Was the person with a mental illness involved in providing care and supervision to (child’s
name)?
1 = No
2 = Yes
[NOTE TO INTERVIEWER: Question #24 is skipped, as it is not applicable at follow-up.]
24a. In the past 6 months, have any members of (child’s name)’s household been convicted of a
crime?
1 = No
2 = Yes
25.

Has anyone in (child’s name)’s biological family had a drinking or drug problem? By biological
family, I mean (child’s name)’s biological parents, grandparents, and siblings.
1 = No
2 = Yes

[NOTE TO INTERVIEWER: Question #25a is skipped, as it is not applicable at follow-up.]
25b. In the past 6 months, has (child’s name) lived in a household in which one of the household
members had a drinking or drug problem?
1 = No [GO TO QUESTION #31]
2 = Yes
25c. Was the person with a drinking or drug problem involved in providing care and supervision
to (child’s name)?
1 = No
2 = Yes
[NOTE TO INTERVIEWER: Questions #26–30 are skipped for “staff as caregiver,” as they are not
applicable for this respondent.]
Now I’m going to ask you some questions related to (child’s name)’s health.
31.

Does (child’s name) have recurring or chronic physical health problems such as allergies, asthma,
migraine headaches, diabetes, epilepsy, cancer, etc.?
1 = No [GO TO QUESTION #33]
2 = Yes

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
6

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Follow-Up (CIQ–RS–F)

CHILD ID:

32.

What recurring or chronic physical health problems does (child’s name) have? [Select all that
apply]
1 = Allergies
2 = Asthma
3 = Cancer
4 = Cerebral palsy
5 = Diabetes
6 = Epilepsy
7 = Migraine headaches
8 = Heart condition
9 = High blood pressure
10 = Overweight
11 = Sickle cell anemia
12 = Spina bifida
13 = Thyroid problems
14 = Other—please specify ____________________________________________
32a. Now or in the past 6 months, has (child’s name) taken medication related to his/her (name of
child’s physical health problems)?
1 = No
2 = Yes
32b. During the past 6 months, have the regular activities (child’s name) participates in (such as
school, social activities, participation in treatment for emotional or behavioral problems,
etc.) been disrupted because of problems related to his/her recurring or chronic physical
health problems?
1 = No
2 = Yes

33.

In the past 6 months, how many times did (child’s name) see a doctor or other primary health care
provider for a physical health problem, not during an emergency room visit?
_____ times [RECORD 0, IF NONE]

34.

During the past 6 months, how many times did (child’s name) have to go to the emergency room to
seek treatment for a physical health problem?
_____ times [RECORD 0, IF NONE]
34a. During the past 6 months, how many times did (child’s name) have to go to the emergency
room to seek treatment as a result of his/her behavioral or emotional problem?
_____ times [RECORD 0, IF NONE]

35.

During the past 6 months, how many times was (child’s name) hospitalized for a physical health
problem?
_____ times [RECORD 0, IF NONE]
35a. [IF 1 OR MORE] What is the total number of days that (child’s name) was hospitalized for a
physical problem in the past 6 months?
_____ days

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
7

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Follow-Up (CIQ–RS–F)

CHILD ID:

36.

Has (child’s name) had a routine physical health exam in the past 6 months?
1 = No
2 = Yes

[NOTE TO INTERVIEWER: Questions #37 and #37a are skipped, as they are not applicable at followup.]
38.

Do any members of (child’s name)’s family have recurring or chronic physical health problems
such as allergies, asthma, migraine headaches, diabetes, epilepsy, cancer, etc.?
1 = No [GO TO QUESTION #39]
2 = Yes

[CARD 4]
38a. In the past 6 months, how much has (child’s name)’s family’s ability to care for him/her been
affected by the chronic health problems of these family members?
1 = Not at all
2 = A little bit
3 = A moderate amount
4 = Quite a bit
5 = A great deal
Sometimes a doctor or psychiatrist prescribes medication for children to help reduce their emotional or
behavioral symptoms. For example, Adderall may be prescribed for Attention-Deficit Disorder.
39.

Now or in the past 6 months, has (child’s name) taken any medication related to his/her emotional
or behavioral symptoms?
1 = No [END OF QUESTIONNAIRE]
2 = Yes

[CARD 5]
39a. Who prescribed these medications 39b. In the past 6 months, how many times did (child’s
for (child’s name)? [Select all that
name) see this doctor for follow-up on these
prescribed medications?
apply]
More
than 6
times

Not at
all

1 time

2 times

1 = Primary care physician/family
physician

1

2

3

4

5

6

2 = Child psychiatrist

1

2

3

4

5

6

3 = General psychiatrist

1

2

3

4

5

6

4 = Pediatrician

1

2

3

4

5

6

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

3–5 times 6 times

888 = Don’t Know
999 = Missing
8

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Follow-Up (CIQ–RS–F)

CHILD ID:

39a. Who prescribed these medications 39b. In the past 6 months, how many times did (child’s
for (child’s name)? [Select all that
name) see this doctor for follow-up on these
prescribed medications?
apply]
More
than 6
times

Not at
all

1 time

2 times

1

2

3

4

5

6

1

2

3

4

5

6

3–5 times 6 times

5 = Other—please specify
________________________
6 = Other—please specify
________________________

[NOTE TO INTERVIEWER: Do not read the medications in the medication table to the caregiver. Record
the caregiver’s response and then circle the appropriate responses in the table.]
39c. [IF YES TO #39] Please tell me the medication(s) that (child’s name) is currently taking or
has taken in the past 6 months.
__________________________________________________________________________
[Select all that apply]
Taking currently or
in the past 6 months
Medication Category

No

Yes

Abilify (aripiprazole)

1

2

Adderall (amphetamine mixed salts)

1

2

Catapres (clonidine)

1

2

Celexa (citalopram)

1

2

Concerta (methylphenidate)

1

2

Daytrana (methylphenidate transdermal system)

1

2

Depakote (valproic acid and derivatives)

1

2

Desyrel (trazodone)

1

2

Dexedrine (dextroamphetamine)

1

2

Effexor (venlafaxine)

1

2

Eskalith (lithium)

1

2

Focalin (dexmethylphenidate)

1

2

Geodon (ziprasidone)

1

2

Haldol (haloperidol)

1

2

Klonopin (clonazepam)

1

2

Lamictal (lamotrigine)

1

2

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
9

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Follow-Up (CIQ–RS–F)

CHILD ID:

Taking currently or
in the past 6 months
Medication Category

No

Yes

Lexapro (escitalopram)

1

2

Lithobid (lithium)

1

2

Lithonate (lithium)

1

2

Metadate (methylphenidate)

1

2

Neurontin (gabapentin)

1

2

Orap (pimozide)

1

2

Paxil (paroxetine)

1

2

Prozac (fluoxetine)

1

2

Remeron (mirtazapine)

1

2

Risperdal (risperidone)

1

2

Ritalin (methylphenidate)

1

2

Seroquel (quetiapine)

1

2

Strattera (atomoxetine)

1

2

Symbyax (olanzapine and fluoxetine)

1

2

Tegretol (carbamazepine)

1

2

Tenex (guanfacine)

1

2

Topamax (topiramate)

1

2

Trileptal (oxcarbazepine)

1

2

Vyvanse (lisdexamfetamine dimesylate)

1

2

Wellbutrin (bupropion)

1

2

Xanax (alprazolam)

1

2

Zoloft (sertraline)

1

2

Zyprexa (olanzapine)

1

2

Other—please specify __________________________

1

2

[NOTE TO INTERVIEWER: Questions #39d–g and #39i are skipped for “staff as caregiver,” as they are
not applicable for this respondent.]

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
10

Caregiver Information Questionnaire,
Revised: Staff as Caregiver—Follow-Up (CIQ–RS–F)

CHILD ID:

I will now read you a statement about any medications that (child’s name) is currently taking, or has taken
in the past 6 months, for his/her emotional or behavioral symptoms. Please tell me how strongly you
agree that the statement reflects your experience.

[CARD 6]
Strongly
Strongly
disagree Disagree Undecided Agree
agree
39h. (Child’s name) takes his/her medication
the way he/she is supposed to.

1

2

3

4

5

[NOTE TO INTERVIEWER: Questions #40–46 are skipped for “staff as caregiver,” as they are not
applicable for this respondent.]

For all variables and data elements:
Date last modified: September 2012

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
11

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

CAREGIVER STRAIN QUESTIONNAIRE (CGSQ)
/

CGSDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

1 = Intake
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

CGSRESP (Respondent for interview)

1 = Caregiver (child’s caregiver in a family, household
environment)

CGSINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

CGSMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

CGSLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Date last modified: September 2012

CHILD ID:

Caregiver Strain Questionnaire (CGSQ)

Please think back over the past 6 months and try to remember how things have been for your family. We
are trying to get a picture of how life has been in your household over that time.
For each question, please tell me which response (which number) fits best.

[CARD]
Not at all A little Somewhat

Quite a
bit

Very
much

In the past 6 months, how much of a problem was the following:
1.

Interruption of personal time resulting from your
child’s emotional or behavioral problem?

1

2

3

4

5

2.

Your missing work or neglecting other duties
because of your child’s emotional or behavioral
problem?

1

2

3

4

5

3.

Disruption of family routines due to your child’s
emotional or behavioral problem?

1

2

3

4

5

4.

Any family member having to do without things
because of your child’s emotional or behavioral
problem?

1

2

3

4

5

Any family member suffering negative mental or
physical health effects as a result of your child’s
emotional or behavioral problem?

1

2

3

4

5

Your child getting into trouble with the
neighbors, the school, the community, or law
enforcement?

1

2

3

4

5

7.

Financial strain for your family as a result of
your child’s emotional or behavioral problem?

1

2

3

4

5

8.

Less attention paid to other family members
because of your child’s emotional or behavioral
problem?

1

2

3

4

5

Disruption or upset of relationships within the
family due to your child’s emotional or
behavioral problem?

1

2

3

4

5

Disruption of your family’s social activities
resulting from your child’s emotional or
behavioral problem?

1

2

3

4

5

5.

6.

9.

10.

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
1

CHILD ID:

Caregiver Strain Questionnaire (CGSQ)

In this section, please continue to look back and try to remember how you have felt during the past 6
months.
For each question, please tell me which response (which number) fits best.

[CARD]
Not at all A little Somewhat

Quite a
bit

Very
much

In the past 6 months:
11.

How isolated did you feel as a result of your
child’s emotional or behavioral problem?

1

2

3

4

5

12.

How sad or unhappy did you feel as a result of
your child’s emotional or behavioral problem?

1

2

3

4

5

13.

How embarrassed did you feel about your
child’s emotional or behavioral problem?

1

2

3

4

5

14.

How well did you relate to your child?

1

2

3

4

5

15.

How angry did you feel toward your child?

1

2

3

4

5

16.

How worried did you feel about your child’s
future?

1

2

3

4

5

17.

How worried did you feel about your family’s
future?

1

2

3

4

5

18.

How guilty did you feel about your child’s
emotional or behavioral problem?

1

2

3

4

5

19.

How resentful did you feel toward your child?

1

2

3

4

5

20.

How tired or strained did you feel as a result of
your child’s emotional or behavioral problem?

1

2

3

4

5

21.

In general, how much of a toll has your child’s
emotional or behavioral problem taken on your
family?

1

2

3

4

5

*Developed by Brannan, Heflinger, & Bickman (1990)

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
2

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

CHILD BEHAVIOR CHECKLIST (CBCL 1½–5)
/

CCBDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
CCBAGE (Child’s age in years and months)

_______ year(s) and _______ month(s)

TIMEFRAM (Assessment period)

1 = Intake
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

CCBRESP (Respondent for interview)

1 = Caregiver (child’s caregiver in a family, household
environment)
2 = Staff as Caregiver (staffperson who has acted as the
child’s day-to-day caregiver for the majority of the past 6
months)

CCBINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

CCBMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

CCBLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Instructions to respondent: I am going to read you a list of items that describe children. For each item that
describes your child now or within the past 6 months, please tell me if the item is very true or often true
of your child, somewhat or sometimes true of your child, or not true of your child. Please answer all items
as well as you can, even if some do not seem to apply to your child. [CARD]

Date last modified: September 2012

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

CHILD BEHAVIOR CHECKLIST (CBCL 6–18)
/

CCBDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
CCBAGE (Child’s age in years and months)

_______ years and _______ month(s)

TIMEFRAM (Assessment period)

1 = Intake
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

CCBRESP (Respondent for interview)

1 = Caregiver (child’s caregiver in a family, household
environment)
2 = Staff as Caregiver (staffperson who has acted as the
child’s day-to-day caregiver for the majority of the past 6
months)

CCBINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

CCBMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

CCBLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Instructions to respondent: I am going to read you a list of items that describe children and youth. For
each item that describes your child now or within the past 6 months, please tell me if the item is very true
or often true of your child, somewhat or sometimes true of your child, or not true of your child. Please
answer all items as well as you can, even if some do not seem to apply to your child. [CARD]

Date last modified: September 2012

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

EDUCATION QUESTIONNAIRE, REVISION 2
(EQ–R2)
/

EQRDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

1 = Intake
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

EQRRESP (Respondent for interview)

1 = Caregiver (child’s caregiver in a family, household
environment)
2 = Staff as Caregiver (staffperson who has acted as the
child’s day-to-day caregiver for the majority of the past 6
months)
3 = Youth without caregiver (independent youth)

EQRINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

EQRMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

EQRLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Date last modified: September 2012

CHILD ID:

Education Questionnaire, Revision 2 (EQ–R2)

This set of questions deals with (child’s name)’s experiences in school. Some questions may not apply to
him/her, but we ask these questions of everyone.
[NOTE TO INTERVIEWER: “School” means preschool through post-secondary education (pre-K
through post-high school education, e.g., college, university, vocational/trade school.) “Preschool”
refers to a beginning group or class enrolling children 3 years or older that is organized to provide
educational experience under professionally qualified teachers during the year or years immediately
preceding kindergarten.]
1.

Has (child’s name) been in school at any time in the past 6 months? This includes preschool,
prekindergarten, kindergarten, home schooling, and post-secondary schools such as college,
university, or vocational or trade schools.
1 = No
2 = Yes [GO TO QUESTION #2]
1a.

Why was he/she not in school?
1 = Has never been in any type of school or received any schooling [GO TO
QUESTION #13]
2 = Dropped out of school before reaching legal age to drop out [GO TO QUESTION
#2c]
3 = Dropped out after reaching the legal age [GO TO QUESTION #2c]
4 = Expelled [GO TO QUESTION #2c]
5 = Suspended [GO TO QUESTION #2c]
6 = Graduated from high school/got GED [GO TO QUESTION #2c]
7 = Physical illness and/or injury [GO TO QUESTION #2c]
8 = Refused to go to school [GO TO QUESTION #2c]
9 = In juvenile detention or jail (and schooling was not provided) [GO TO QUESTION
#2c]
10 = Asked to leave school (e.g., due to behavior) [GO TO QUESTION #2c]
11 = No instruction provided while waiting for another placement [GO TO QUESTION
#2c]
12 = Other—please specify ____________________________________________
___________________________________________ [GO TO QUESTION #2c]

2.

Is (child’s name) in school now?
1 = No [GO TO QUESTION #2b]
2 = Yes

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
1

CHILD ID:

2a.

Education Questionnaire, Revision 2 (EQ–R2)

Which grade is (child’s name) in now? If (child’s name)’s school does not use grade levels,
please estimate as best you can which grade he/she is in.
1 = Preschool program
2 = Kindergarten
3 = First grade
4 = Second grade
5 = Third grade
6 = Fourth grade
7 = Fifth grade
8 = Sixth grade
9 = Seventh grade
10 = Eighth grade
11 = Ninth grade
12 = Tenth grade
13 = Eleventh grade
14 = Twelfth grade
15 = Receiving adult education to get a GED
16 = Attending vocational or trade school
17 = Attending 2-year college
18 = Attending 4-year college or university
19 = Other—please specify ____________________________________________
[GO TO QUESTION #2d]

2b.

Why is he/she not in school now?
2 = Dropped out of school before reaching legal age to drop out
3 = Dropped out after reaching the legal age
4 = Expelled
5 = Suspended
6 = Graduated from high school/got GED
7 = Physical illness and/or injury
8 = Refuses to go to school
9 = In juvenile detention or jail (and schooling is not provided)
10 = Asked to leave school (e.g., due to behavior)
11 = No instruction provided while waiting for another placement
12 = Other—please specify ____________________________________________
________________________________________________________________

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
2

CHILD ID:

2c.

Education Questionnaire, Revision 2 (EQ–R2)

Which grade did (child’s name) most recently complete? If (child’s name)’s school does not
use grade levels, please estimate as best you can which grade he/she completed.
1 = Preschool program [GO TO QUESTION #13]
2 = Kindergarten
3 = First grade
4 = Second grade
5 = Third grade
6 = Fourth grade
7 = Fifth grade
8 = Sixth grade
9 = Seventh grade
10 = Eighth grade
11 = Ninth grade
12 = Tenth grade
13 = Eleventh grade
14 = Twelfth grade
15 = Received a GED [END OF QUESTIONNAIRE]
16 = Some vocational or trade school [END OF QUESTIONNAIRE]
17 = Vocational or trade school [END OF QUESTIONNAIRE]
18 = Some college [END OF QUESTIONNAIRE]
19 = 2-year college degree [END OF QUESTIONNAIRE]
20 = 4-year college or university degree [END OF QUESTIONNAIRE]
21 = Other—please specify __________________________ [GO TO QUESTION #13]
[IF RESPONDENT ANSWERED YES TO QUESTION #1 AND CHILD IS IN
KINDERGARDEN TO TWELFTH GRADE, GO TO QUESTION #2d.]
[IF RESPONDENT ANSWERED NO TO QUESTION #1 AND CHILD IS IN
KINDERGARDEN TO TWELFTH GRADE, GO TO QUESTION #13.]

2d.

In the past 6 months, has (child’s name) repeated a grade in school?
1 = No
2 = Yes

For the following questions, please think about what happened while (child’s name) was in school during
the past 6 months.
3.

When school was in session, did (child’s name) ever miss school for any reason in the past 6
months? This includes excused as well as unexcused absences.
1 = No [GO TO QUESTION #4]
2 = Yes

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
3

CHILD ID:

Education Questionnaire, Revision 2 (EQ–R2)

[CARD 1]
3a.

How often was he/she usually absent in the past 6 months? This includes excused and
unexcused absences.
0 = Less than 1 day per month [GO TO QUESTION #4]
1 = About 1 day a month [GO TO QUESTION #3b]
2 = About 1 day every 2 weeks [GO TO QUESTION #3b]
3 = About 1 day a week [GO TO QUESTION #3b]
4 = 2 days per week [GO TO QUESTION #3b]
5 = 3 or more days per week [GO TO QUESTION #3b]

[CARD 2]
3b.

In the past 6 months, to what extent do you think (child’s name)’s school attendance was
affected by his/her behavioral or emotional problems?
1 = Not at all
2 = A little bit
3 = A moderate amount
4 = Quite a bit
5 = Extremely

3c.

In the past 6 months, to what extent did (child’s name)’s school provide support to help
improve (child’s name)’s attendance?
1 = Not at all
2 = A little bit
3 = A moderate amount
4 = Quite a bit
5 = Extremely

4.

In the past 6 months, how many different schools did (child’s name) attend?
_____ schools

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
4

CHILD ID:

Education Questionnaire, Revision 2 (EQ–R2)

[CARD 3]
4a1. In the past 6 months, what kinds of schools and school settings was he/she in? [Select all that
apply]
1 = Regular public day school
2 = Regular private day or boarding school/academy (e.g., private preparatory school,
parochial or religious school)
3 = Home schooling (e.g., caregiver or other family member provides schooling in the
home)
4 = Home-based instruction (e.g., teacher comes to home and educates child there,
and/or teacher teaches child through distance learning by Internet videoconferencing, or by sending assignments and feedback on work completed through
the mail)
5 = Alternative program or special education day school, not based in a regular public
or private school building (e.g., instruction is provided as part of a day treatment
program OR entire school is devoted to meeting the needs of special education
students and/or students with emotional or behavioral problems OR Interim
Alternative Education Setting or IAES—this kind of setting is often used because
of a severe discipline problem such as bringing a weapon or drugs to school or
making severe threats against others)
6 = Receiving schooling in 24-hour psychiatric and/or medical hospital setting
7 = Receiving schooling in 24-hour juvenile justice facility/detention center/jail
8 = Receiving schooling in 24-hour residential treatment center/group home/shelter
9 = Post-secondary school [IF YOUTH ATTENDED ONLY ONE POST-SECONDARY
SCHOOL, GO TO QUESTION #5c]
10 = Preschool
11 = Head Start
12 = Other—please specify ____________________________________________
[NOTE TO INTERVIEWER: If more than one school or setting indicated, ask #4a2 and #4b.]

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
5

CHILD ID:

Education Questionnaire, Revision 2 (EQ–R2)

4a2. In which of these schools or school settings did (child’s name) spend the most time during the
past 6 months?
1 = Regular public day school
2 = Regular private day or boarding school/academy (e.g., private preparatory school,
parochial or religious school)
3 = Home schooling (e.g., caregiver or other family member provides schooling in the
home)
4 = Home-based instruction (e.g., teacher comes to home and educates child there,
and/or teacher teaches child through distance learning by Internet videoconferencing, or by sending assignments and feedback on work completed through
the mail)
5 = Alternative program or special education day school, not based in a regular public
or private school building (e.g., instruction is provided as part of a day treatment
program OR entire school is devoted to meeting the needs of special education
students and/or students with emotional or behavioral problems OR Interim
Alternative Education Setting or IAES—this kind of setting is often used because
of a severe discipline problem such as bringing a weapon or drugs to school or
making severe threats against others)
6 = Receiving schooling in 24-hour psychiatric and/or medical hospital setting
7 = Receiving schooling in 24-hour juvenile justice facility/detention center/jail
8 = Receiving schooling in 24-hour residential treatment center/group home/shelter
9 = Post-secondary school
10 = Preschool
11 = Head Start
12 = Other—please specify ____________________________________________
4b.

Did (child’s name) attend more than one school because of his/her behavioral or emotional
problems?
1 = No
2 = Yes

5.

In the past 6 months, did (child’s name) have an Individualized Education Program?
1 = No
2 = Yes [GO TO QUESTION #5b1]

[NOTE TO INTERVIEWER: If necessary, clarify that special education may be provided to many
different children for many different reasons. For example, children with developmental disabilities;
mental retardation; hearing, vision, or speech difficulties; other physical disabilities; learning
disabilities; emotional problems; and/or behavioral problems may receive special education.]

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
6

CHILD ID:

5a.

Education Questionnaire, Revision 2 (EQ–R2)

What was the reason that (child’s name) did not have an IEP?
1 = Doing well and did not need an IEP
2 = Never referred, but needs to be
3 = Eligibility was under review
4 = Was assessed and found ineligible
5 = Was never assessed for special education
6 = Other special education plan (e.g., 504, behavior management, vocational training,
or transition plans)
7 = Other—please specify __________________________________________
[IF CHILD HAS NOT ATTENDED POST-SECONDARY SCHOOL IN THE PAST 6
MONTHS, GO TO QUESTION #6]
[IF CHILD HAS ATTENDED POST-SECONDARY SCHOOL IN THE PAST 6 MONTHS,
GO TO QUESTION #5c]

[CARD 4]
5b1. What was the main reason that (child’s name) had an IEP?
1 = Behavioral and/or emotional problems
2 = Learning disability
3 = Physical disability (for example, an orthopedic disability such as a missing limb)
4 = Developmental disability and/or mental retardation
5 = Vision and/or hearing impairment
6 = Speech impairment
7 = Other—please specify ____________________________________________
5b2. Were there other reasons that (child’s name) had an IEP?
1 = No [GO TO QUESTION #6]
2 = Yes
5b3. What were the other reasons that (child’s name) had an IEP? [Select all that apply]
1 = Behavioral and/or emotional problems
2 = Learning disability
3 = Physical disability (for example, an orthopedic disability such as a missing limb)
4 = Developmental disability and/or mental retardation
5 = Vision and/or hearing impairment
6 = Speech impairment
7 = Other—please specify __________________________________________
[IF CHILD HAS NOT ATTENDED POST-SECONDARY SCHOOL IN THE PAST 6
MONTHS, GO TO QUESTION #6]
5c.

In the past 6 months, did (child’s name)’s post-secondary school provide any educational
support, such as extra time for tests or tutoring to assist with academic achievement?
1 = No
2 = Yes [GO TO QUESTION #5e1]

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
7

CHILD ID:

5d.

Education Questionnaire, Revision 2 (EQ–R2)

What was the reason that (child’s name) did not receive educational support?
1 = Doing well and did not need any educational support
2 = Post-secondary school does not provide any educational support
3 = Educational support had not been requested
4 = Other—please specify __________________________________________
[IF CHILD ONLY ATTENDED POST-SECONDARY SCHOOL IN THE PAST 6 MONTHS,
GO TO QUESTION #9]

5e1. What was the main reason that (child’s name) received educational support?
1 = Behavioral and/or emotional problems
2 = Learning disability
3 = Physical disability (for example, an orthopedic disability such as a missing limb)
4 = Developmental disability and/or mental retardation
5 = Vision and/or hearing impairment
6 = Speech impairment
7 = Other—please specify ____________________________________________
5e2. Were there other reasons that (child’s name) received educational support?
1 = No [GO TO QUESTION #6]
2 = Yes
5e3. What were the other reasons that (child’s name) received educational support? [Select all that
apply]
1 = Behavioral and/or emotional problems
2 = Learning disability
3 = Physical disability (for example, an orthopedic disability such as a missing limb)
4 = Developmental disability and/or mental retardation
5 = Vision and/or hearing impairment
6 = Speech impairment
7 = Other—please specify __________________________________________
[IF CHILD ONLY ATTENDED POST-SECONDARY SCHOOL IN THE PAST 6 MONTHS,
GO TO QUESTION #9]
6.

Did (child’s name) receive special education?
1 = No [GO TO QUESTION #7]
2 = Yes

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
8

CHILD ID:

6a.

Education Questionnaire, Revision 2 (EQ–R2)

Which best describes the special education classes that (child’s name) took?
1 = Special education classes where all the children in the class are receiving special
education for all or most of the day, often referred to as self-contained. Children in
these classes may spend a portion of their day in general education classes, such as
art, music, and P.E.
2 = Special education classes where all the children leave their general education class
to receive special education instruction, in specific subjects, for a portion of the
day. This is sometimes referred to as resource services or a pullout program.
3 = Special education provided in the general education class, where some children
receive special education and others do not. This is sometimes referred to as
inclusion.
4 = Special education provided on as-needed basis. Children do not receive support on
a regular basis, can get support of they want it.

[NOTE TO INTERVIEWER: If necessary, please clarify for respondent that these classes may be cotaught by a regular education instructor and special education teacher, or by a teacher and an aide. A
special education teacher may come to the class for part of the day to provide specialized instruction.]
7.

In the past 6 months, did (child’s name) have a one-on-one classroom aide for any reason, for any
part of the school day? For example, a child might have an aide to help him/her with schoolwork, to
help manage the child’s behavior, and/or to help the child develop behavioral and social skills.
[This does not include out-of-class visits to a counselor.]
1 = No
2 = Yes

8.

In the past 6 months, were any of the following disciplinary actions taken toward (child’s name)?
1 = Suspended (in-school and out-of-school) [GO TO QUESTION #8a]
2 = Expelled [GO TO QUESTION #8a]
3 = Suspended AND expelled [GO TO QUESTION #8a]
4 = Neither suspended nor expelled [GO TO QUESTION #9]
5 = Other—please specify __________________________
8a.

Did (child’s name) have a school disciplinary hearing or tribunal?
1 = No
2 = Yes

8b.

As a result of the suspension and/or expulsion, was a plan developed to manage or improve
(child’s name)’s behavior, or was an existing plan revised or changed?
1 = No
2 = Yes

8c.

[IF SUSPENDED] During the past 6 months, approximately how many days was (child’s
name) in in-school suspension?
_____ days

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
9

CHILD ID:

Education Questionnaire, Revision 2 (EQ–R2)

[NOTE TO INTERVIEWER: If necessary, clarify for the respondent that in-school suspension is when
children are sent to a suspension room for all or part of the day. A teacher or monitor is assigned to the
room, and children may be required to do assignments provided by their regular classroom teachers. The
length of suspension may vary widely but usually it is for a minimum of a day and a maximum of 10 days.
The child is expected to return to his/her regular classes after the suspension. In-school suspension is
generally considered to be a less severe punishment than out-of-school suspension.]
8d.

[IF SUSPENDED] During the past 6 months, approximately how many days was (child’s
name) in out-of-school suspension?
_____ days

[NOTE TO INTERVIEWER: If necessary, clarify for the respondent that out-of-school suspension is a
temporary period during which a child is forbidden to go to school. The child is generally not required to
continue with schoolwork during this time. The length of a suspension may vary widely but usually it is
for a minimum of a day and a maximum of 10 days. The child is expected to return to his/her school after
the suspension. Out-of-school suspension is generally considered to be a more severe punishment than inschool suspension.]
8e.

[IF EXPELLED] During the past 6 months, approximately how many times was (child’s
name) expelled?
_____ times

[NOTE TO INTERVIEWER: This is when a child is removed from a school and is not expected to ever
return. The child may be sent to an alternative school or a teacher may visit the child to teach him/her at
home. It is also possible for a child to have multiple school expulsions. For example, if a child is expelled
from one school system and transferred to another system, he/she can be expelled from the second system,
resulting in multiple school expulsions. Some school systems may allow a child to return to his/her
regular home school later, if the child’s behavior or problems have improved.]
8f.

[IF EXPELLED] Was any kind of education provided to (child’s name) while he/she was
expelled? This might include a transfer to another school, home schooling, or home visits by a
teacher.
1 = No
2 = Yes

9.

Does (child’s name) participate in any extracurricular activities at school (such as sports, clubs,
band, etc.)?
1 = No [GO TO QUESTION #10]
2 = Yes

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
10

CHILD ID:

Education Questionnaire, Revision 2 (EQ–R2)

[CARD 1]
9a.

How often does (child’s name) participate in these extracurricular activities at school?
0 = Less than 1 day per month
1 = About 1 day a month
2 = About 1 day every 2 weeks
3 = About 1 day a week
4 = 2 days per week
5 = 3 or more days per week

10.

In general, does (child’s name) get along with his/her friends at school?
1 = No
2 = Yes

11.

Does (child’s name) have a favorite teacher or another favorite adult at school?
1 = No
2 = Yes

12.

Now I would like to ask you about (child’s name)’s grades during this school year. Did he/she get
grades?
1 = No [GO TO QUESTION #12b]
2 = Yes
12a. Overall, across all subjects, has he/she mostly gotten . . . [READ CATEGORIES, CODE
ONE]
1 = A’s [GO TO QUESTION #12c]
2 = A’s and B’s [GO TO QUESTION #12c]
3 = B’s [GO TO QUESTION #12c]
4 = B’s and C’s [GO TO QUESTION #12c]
5 = C’s [GO TO QUESTION #12c]
6 = C’s and D’s [GO TO QUESTION #12c]
7 = D’s [GO TO QUESTION #12c]
8 = D’s and F’s [GO TO QUESTION #12c]
9 = F’s [GO TO QUESTION #12c]
10 = School does not give these grades [GO TO QUESTION #12b]
[IF RESPONSE DOES NOT FIT CATEGORIES, e.g., A’s AND F’s, SPECIFY RESPONSE = 11]
11 = Other—please specify _________________________ [GO TO QUESTION #12c]

[CARD 5]
12b. Overall, would you describe his/her work at school as . . .
1 = Excellent
2 = Above average
3 = Average
4 = Below average
5 = Failing

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
11

CHILD ID:

Education Questionnaire, Revision 2 (EQ–R2)

[CARD 2]
12c. In the past 6 months, to what extent do you think (child’s name)’s grades or school
performance were affected by his/her behavioral or emotional problems?
1 = Not at all
2 = A little bit
3 = A moderate amount
4 = Quite a bit
5 = Extremely
[IF YOUTH ATTENDS POST-SECONDARY EDUCATION, THEN END OF QUESTIONNAIRE]
13.

Has (child’s name) attended childcare or an afterschool care program at any time in the past 6
months?
1 = No
2 = Yes [GO TO QUESTION #14]
13b. Were any of the reasons that (child’s name) was not in childcare or an afterschool care
program related to his/her behavioral or emotional problems?
1 = No [END OF QUESTIONNAIRE]
2 = Yes [END OF QUESTIONNAIRE]

14.

During the past 6 months, on average, how many hours per week did (child’s name) attend childcare
or an afterschool care program?
_____ hours
14a. Was (child’s name)’s childcare or afterschool care program attendance affected by his/her
behavioral or emotional problems?
1 = No [GO TO QUESTION #15]
2 = Yes
14b. Did (child’s name)’s childcare or afterschool care program(s) provide any support to help
improve (child’s name)’s attendance?
1 = No
2 = Yes

15.

During the past 6 months, did (child’s name) attend more than one childcare center or afterschool
care program because of his/her behavioral or emotional problems?
1 = No
2 = Yes

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
12

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

LIVING SITUATIONS QUESTIONNAIRE (LSQ)
/

LSQDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

1 = Intake
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

LSQRESP (Respondent for interview)

1 = Caregiver (child’s caregiver in a family, household
environment)
2 = Staff as Caregiver (staffperson who has acted as the
child’s day-to-day caregiver for the majority of the past 6
months)
3 = Youth without caregiver (independent youth)

LSQINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

LSQMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

LSQLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Date last modified: September 2012

CHILD ID:

Living Situations Questionnaire (LSQ)

[NOTE TO INTERVIEWER: For each question, you must code the place that the caregiver describes
using the 14 “Living Situation” codes, and the adults who have primary responsibility for the child using
the 22 “Lives With” codes below. If necessary, two “Lives With” codes may be selected for each living
situation. Please see the pages at the end of the questionnaire for a more detailed description of the
codes, including site-specific names of placements.]
Living Situation:
1
2
3
4
5
6
7
8
9
10
11
12
13
14

Homeless
Home (house/apartment/trailer)
School dormitory
Camp (recreational)
Emergency shelter
Foster home
Therapeutic/specialized foster home
Group home
Hospital—medical
Residential treatment center/therapeutic camp
Hospital—psychiatric or psychiatric unit
Youth justice related (juvenile detention, youth correctional facility)
Adult justice related (jail, prison)
Other

Lives With: (Adults[s] with primary caregiving responsibility for child or youth)
Biological Family

Relative (non-parent)

1
2
3
4
5
6
7
8

12
13
14
15
16

Biological parents
Biological mother, adoptive father
Biological mother, with partner
Biological mother, no partner
Biological father, adoptive mother
Biological father, with partner
Biological father, no partner
Split parenting

Adoptive Family
9 2 adoptive parents
10 1 adoptive parent, with partner
11 1 adoptive parent, no partner

For all variables and data elements:
Date last modified: December 2009

2 grandparents
1 grandparent, with partner
1 grandparent, no partner
Other relative, with partner
Other relative, no partner

Non-Relative
17 Foster parent(s)
18 Staff
19 Other caregiving adult
Independent Living
20 Alone
21 With friend
22 Supervised

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
1

CHILD ID:

Living Situations Questionnaire (LSQ)

[NOTE TO INTERVIEWER: Please indicate all the places the child has lived or stayed during the past 6
months, starting with the current living situation. Prompt respondent to think about all the places the
child may have lived or stayed, including brief stays (e.g., overnight stays) at a hospital, a treatment
center, a crisis shelter, etc. The only exception is brief stays (of less than 2 weeks) for leisure reasons
(e.g., child visited grandparents for spring break). Do not code these leisure stays using a new or
different code but simply code these stays the same as the child’s primary family living situation (e.g.,
mother’s home). If there is no primary family living situation (e.g., the child lives primarily in an out-ofhome placement setting), code the living situation the child will return to after the leisure stay. Each day
of the 6-month period must be accounted for (i.e., total of all living situations should be 180 days) and
each time period noted should be associated with only one living situation.]
I’d like to ask you about where (child’s name) has lived or stayed in the past 6 months and who have been
his/her caregivers in those places. Let’s talk about where he/she lives or stays now and then about other
places he/she may have lived or stayed.
a.
Living
Situation
code

[USE TIMELINE CARD TO PROMPT
RESPONDENT]

1a.
1b.
1c.

b1.
Lives
With
code

b2.
Lives
With
code

c.
Number of days in
living situation in
past 6 months

Where does (child’s name) live now?
Who does (child’s name) live with now?
For how many days has he/she lived here?

[Probe for name of place, description of place, and who lives there.]

2a.
2b.
2c.

Where did he/she live before this place?
Who did he/she live with before this place?
For how many days did he/she live there?

[Probe for name of place, description of place, and who lives there.]

3a.
3b.
3c.

Where did he/she live before this place?
Who did he/she live with before this place?
For how many days did he/she live there?

[Probe for name of place, description of place, and who lives there.]

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
2

CHILD ID:

Living Situations Questionnaire (LSQ)

a.
Living
Situation
code

[USE TIMELINE CARD TO PROMPT
RESPONDENT]

4a.
4b.
4c.

b1.
Lives
With
code

b2.
Lives
With
code

c.
Number of days in
living situation in
past 6 months

Where did he/she live before this place?
Who did he/she live with before this place?
For how many days did he/she live there?

[Probe for name of place, description of place, and who lives there.]

5a.
5b.
5c.

Where did he/she live before this place?
Who did he/she live with before this place?
For how many days did he/she live there?

[Probe for name of place, description of place, and who lives there.]

6a.
6b.
6c.

Where did he/she live before this place?
Who did he/she live with before this place?
For how many days did he/she live there?

[Probe for name of place, description of place, and who lives there.]

7a.
7b.
7c.

Where did he/she live before this place?
Who did he/she live with before this place?
For how many days did he/she live there?

[Probe for name of place, description of place, and who lives there.]

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
3

CHILD ID:

Living Situations Questionnaire (LSQ)

a.
Living
Situation
code

[USE TIMELINE CARD TO PROMPT
RESPONDENT]

8a.
8b.
8c.

b1.
Lives
With
code

b2.
Lives
With
code

c.
Number of days in
living situation in
past 6 months

Where did he/she live before this place?
Who did he/she live with before this place?
For how many days did he/she live there?

[Probe for name of place, description of place, and who lives there.]

9a.
9b.
9c.

Where did he/she live before this place?
Who did he/she live with before this place?
For how many days did he/she live there?

[Probe for name of place, description of place, and who lives there.]

10a. Where did he/she live before this place?
10b. Who did he/she live with before this place?
10c. For how many days did he/she live there?
[Probe for name of place, description of place, and who lives there.]

11a. Where did he/she live before this place?
11b. Who did he/she live with before this place?
11c. For how many days did he/she live there?
[Probe for name of place, description of place, and who lives there.]

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
4

CHILD ID:

Living Situations Questionnaire (LSQ)

a.
Living
Situation
code

[USE TIMELINE CARD TO PROMPT
RESPONDENT]

b1.
Lives
With
code

b2.
Lives
With
code

c.
Number of days in
living situation in
past 6 months

12a. Where did he/she live before this place?
12b. Who did he/she live with before this place?
12c. For how many days did he/she live there?
[Probe for name of place, description of place, and who lives there.]

13a. Where did he/she live before this place?
13b. Who did he/she live with before this place?
13c. For how many days did he/she live there?
[Probe for name of place, description of place, and who lives there.]

14a. Where did he/she live before this place?
14b. Who did he/she live with before this place?
14c. For how many days did he/she live there?
[Probe for name of place, description of place, and who lives there.]

15a. Where did he/she live before this place?
15b. Who did he/she live with before this place?
15c. For how many days did he/she live there?
[Probe for name of place, description of place, and who lives there.]

*Adapted from Fabry, Hawkins, Luster, & Almeida (1990) and Hawkins, Almeida, Fabry, & Reitz (1992)

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
5

[NOTE TO INTERVIEWER: Please use these categories to code the different places where the child has
lived. If you are unsure of how a placement should be coded, write a detailed description of the situation
in the box provided after each question and bring this item to the attention of your site evaluator.]
Living Situation Categories:
1

No place to stay
Homeless, staying anywhere available from night to night.

2

Home
Living in a house, apartment, or trailer (i.e., living alone, with biological or adoptive parents,
relatives, or friend[s]).

3

School dormitory
Living out of the home in boarding school arrangement (i.e., private school or academy, without a
treatment component).

4

Camp
i.e., recreational, religious, summer camp

site-specific names
_______________________________________
_______________________________________
_______________________________________

5

Emergency shelter
Living temporarily in a private home or group
living arrangement during a crisis situation.
Extensive support and supervision provided.

site-specific names
_______________________________________
_______________________________________
_______________________________________

6

Foster home
Living in standard foster care arrangement
without added support or in-house treatment
component.

site-specific names
_______________________________________
_______________________________________
_______________________________________

7

8

Therapeutic/specialized foster care
Living in a private home with care provided by
foster parents who are trained to care for
children with special needs and has an
identifiable treatment or support component
(e.g., intensive in-home intervention, case
management, physical therapy, etc.).
Group home
Alternative living arrangement in which child
lives with a small number of other children (e.g.,
3–9) with special needs. 24-hour supervision is
provided along with long-term treatment and
supports.

site-specific names
_______________________________________
_______________________________________
_______________________________________

site-specific names
_______________________________________
_______________________________________
_______________________________________

9

Hospital (medical)
Living in inpatient unit of medical hospital for
treatment of non-mental health-related problems.

site-specific names
_______________________________________
_______________________________________
_______________________________________

10

11

Residential treatment center/therapeutic camp
Alternative group living arrangement for
children with intensive mental health needs with
10 or more children. Lengths of stay are
generally longer than in hospitals, may be for
alcohol/drug or non-substance use treatment.
Hospital (psychiatric)
Inpatient unit of psychiatric or medical hospital
with 24-hour supervision. Intensive mental
health treatment component.

site-specific names
_______________________________________
_______________________________________
_______________________________________
site-specific names
_______________________________________
_______________________________________
_______________________________________

12

Juvenile justice related
Juvenile detention center or incarceration in a “youth only” correctional facility with high structure
and supervision.

13

Adult justice related
An adult locked correctional facility with high structure and high supervision (i.e., jail or prison).

14

Other—please specify ______________________________________________________________
_________________________________________________________________________________

Lives With Categories:
Biological Family
1

Biological parents
Living with two biological caregivers

2

Biological mother, adoptive father
Living with biological mother and adoptive father

3

Biological mother, with partner
Living with biological mother and mother’s partner, who is neither the child’s biological nor adoptive
parent. The partner may be the child’s step-parent.

4

Biological mother, no partner
Living with biological mother

5

Biological father, adoptive mother
Living with biological father and adoptive mother

6

Biological father, with partner
Living with biological father and father’s partner, who is neither the child’s biological nor adoptive
parent. The partner may be the child’s step-parent.

7

Biological father, no partner
Living with biological father

8

Split parenting
Living about half with mother and half with father (usually joint custody situation)

Adoptive Family
9

2 adoptive parents
Living with two adoptive parents

10 1 adoptive parent, with partner
Living with one adoptive parent and the parent’s partner. The partner may be the child’s step-parent.
11 1 adoptive parent, no partner
Living with one adoptive parent
Relative (non-parent)
12 2 grandparents
Living with two grandparents
13 1 grandparent, with partner
Living with one grandparent and the grandparent’s partner
14 1 grandparent, no partner
Living with one grandparent
15 Other relative, with partner
Living with a relative other than a parent or grandparent (e.g., sibling, aunt, uncle, cousin) and the
relative’s partner. The relative’s partner may also be a relative (e.g., caregivers are child’s aunt and
uncle).
16 Other relative, no partner
Living with a relative other than a parent or grandparent (e.g., sibling, aunt, uncle, cousin)

Non-Relative
17 Foster parent(s)
Living with one or two foster parents
18 Staff
Living in a situation in which care is provided by trained professionals or other staff (e.g., doctors and
nurses in a hospital, juvenile detention staff, emergency shelter staff)
19 Other caregiving adult
Living with a non-relative, non-paid adult who acts as a caregiver to the child (e.g., family friend)
Independent Living
20 Alone
Living alone and unsupervised
21 With friend
Living unsupervised with one or more “unpaid” friends or roommates
22 Supervised
Living independently but with a person who provides minimal supervision (i.e., with recruited
mentor, professional housemate, or other “paid” roommate)

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

BEHAVIORAL AND EMOTIONAL RATING
SCALE—Second Edition, Parent Rating Scale
(BERS–2C)
/

BRCDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

1 = Intake
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

BRCRESP (Respondent for interview)

1 = Caregiver (child’s caregiver in a family, household
environment)
2 = Staff as Caregiver (staffperson who has acted as the
child’s day-to-day caregiver for the majority of the past 6
months)

BRCINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

BRCMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

BRCLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Instructions to respondent: This scale contains a series of statements that are used to rate your child’s
behaviors and emotions in a positive way. After I read each statement, tell me which description best
describes your child’s status over the past 6 months. Rate each statement to the best of your knowledge of
your child. Rate all 57 items by the following criteria: the statement is very much like your child, like your
child, not much like your child, or not at all like your child. [CARD]

Date last modified: September 2012

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

COLUMBIA IMPAIRMENT SCALE (CIS)
/

CISDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

1 = Intake
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

CISRESP (Respondent for interview)

1 = Caregiver (child’s caregiver in a family, household
environment)
2 = Staff as Caregiver (staffperson who has acted as the
child’s day-to-day caregiver for the majority of the past 6
months)

CISINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

CISMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

CISLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Date last modified: September 2012

CHILD ID:

Columbia Impairment Scale (CIS)

This set of questions is about problems that some children have in different areas of their life. For each
potential problem, please think about (child’s name) and tell me how much of a problem you think it has
been for him/her during the past 6 months. Then, describe the extent of the problem on a scale from 0 to
4, with 0 being no problem, 1–3 being some problem, and 4 being a very big problem.

[CARD]
No
problem

A very
big
problem

Some problem

In general, how much of a problem do you think (child’s name) has with:
1.

Getting into trouble?

0

1

2

3

4

2.

Getting along with his/her mother or his/her
female caregiver?

0

1

2

3

4

3.

Getting along with his/her father or his/her male
caregiver?

0

1

2

3

4

4.

Feeling unhappy or sad?

0

1

2

3

4

How much of a problem would you say he/she has:
5.

With his/her behavior at school (or job)?

0

1

2

3

4

6.

With having fun?

0

1

2

3

4

7.

Getting along with adults other than you or
his/her father/mother?

0

1

2

3

4

How much of a problem does he/she have:
8.

With feeling nervous or worried?

0

1

2

3

4

9.

Getting along with his/her brother(s)/sister(s)?

0

1

2

3

4

10.

Getting along with other kids his/her age?

0

1

2

3

4

How much of a problem would you say he/she has:
11.

Getting involved in activities like sports or
hobbies?

0

1

2

3

4

12.

With his/her schoolwork (doing his/her job)?

0

1

2

3

4

13.

With his/her behavior at home?

0

1

2

3

4

*Developed by Bird et al. (1993)

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
1

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

PARENTING STRESS INDEX (PSI)
/

PSIDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

1 = Intake
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

PSIRESP (Respondent for interview)

1 = Caregiver (child’s caregiver in a family, household
environment)

PSIINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

PSIMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

PSILANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Instructions to respondent: This questionnaire contains 36 statements. For each statement, please focus on
(child’s name) and tell me whether you strongly agree with the statement, agree with the statement, are
not sure, disagree with the statement, or strongly disagree with the statement. While you may not find a
response that exactly states your feelings, please tell me the response that comes closest to describing how
you feel now or within the past 6 months. [CARD]

Date last modified: September 2012

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

DEVEREUX EARLY CHILDHOOD
ASSESSMENT—INFANTS (DECA 1–18M)
/

DECDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
DECAGE (Child’s age in months)

_______ month(s)

TIMEFRAM (Assessment period)

1 = Intake
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

DECRESP (Respondent for interview)

1 = Caregiver (child’s caregiver in a family, household
environment)
2 = Staff as Caregiver (staffperson who has acted as the
child’s day-to-day caregiver for the majority of the past 6
months)

DECINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

DECMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

DECLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Instructions to respondent: I am going to read you a list of behaviors seen in some infants. For each
behavior, please tell me how often you saw the behavior during the past 6 months: never, rarely,
occasionally, frequently, or very frequently. Answer each question carefully. There are no right or wrong
answers. Please answer every item. [CARD]

Date last modified: September 2012

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

DEVEREUX EARLY CHILDHOOD
ASSESSMENT—TODDLERS (DECA 18–36M)
/

DECDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
DECAGE (Child’s age)

_______ month(s)

TIMEFRAM (Assessment period)

1 = Intake
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

DECRESP (Respondent for interview)

1 = Caregiver (child’s caregiver in a family, household
environment)
2 = Staff as Caregiver (staffperson who has acted as the
child’s day-to-day caregiver for the majority of the past 6
months)

DECINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

DECMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

DECLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Instructions to respondent: I am going to read you a list of behaviors seen in some infants. For each
behavior, please tell me how often you saw the behavior during the past 6 months: never, rarely,
occasionally, frequently, or very frequently. Answer each question carefully. There are no right or wrong
answers. Please answer every item. [CARD]

Date last modified: September 2012

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

DEVEREUX EARLY CHILDHOOD
ASSESSMENT—PRESCHOOL (DECA 2–5Y)
/

DECDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
DECAGE (Child’s age)

_______ year(s)

TIMEFRAM (Assessment period)

1 = Intake
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

DECRESP (Respondent for interview)

1 = Caregiver (child’s caregiver in a family, household
environment)
2 = Staff as Caregiver (staffperson who has acted as the
child’s day-to-day caregiver for the majority of the past 6
months)

DECINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

DECMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

DECLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Instructions to respondent: I am going to read you a list of behaviors seen in some infants. For each
behavior, please tell me how often you saw the behavior during the past 6 months: never, rarely,
occasionally, frequently, or very frequently. Answer each question carefully. There are no right or wrong
answers. Please answer every item. [CARD]

Date last modified: September 2012

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 6 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

PRESCHOOL BEHAVIORAL AND EMOTIONAL
RATING SCALE (PreBERS)
/

PBRDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

1 = Intake
2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

PBRRESP (Respondent for interview)

1 = Caregiver (child’s caregiver in a family, household
environment)
2 = Staff as Caregiver (staffperson who has acted as the
child’s day-to-day caregiver for the majority of the past 6
months)

PBRINTV (Who administered interview)

1 = Person providing services to child
2 = Data collector

PBRMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

PBRLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Instructions to respondent: This scale contains a series of statements that are used to rate your child’s
behaviors and emotions in a positive way. After I read each statement, tell me which description best
describes your child’s status over the past 6 months. Rate each statement to the best of your knowledge of
your child. Rate all 42 items by the following criteria: the statement is very much like the child, like the
child, not much like the child, or not at all like the child. [CARD]

Date last modified: September 2012

■
■
■

Preschool Norms

Preschool Behavioral and Emotional Rating Scale

Head Start Norms

PreBERS

ECSE Norms

Summary/Response Form
Michael H. Epstein

Lori Synhorst

Section 1. Identifying Information
Name _______________________________________

■

Female

Male

■

Age ________

Parent/Guardian ________________________________
School ______________________________________

Date of Birth

________ ________ ________

Rater’s Name __________________________________
Relationship to Child _____________________________

PL
E

Date of Rating

Year
Month
Day
________ ________ ________

Examiner’s Name
Examiner’s Title

Section 2. Results of the PreBERS

Raw
Score

%ile
Rank

1. Emotional Regulation (ER)

______

______

1

______________

2. School Readiness (SR)

______

______

1

______________

______

______

1

______________

______

______

1

______________

3. Social Confidence (SC)
4. Family Involvement (FI)

M

Subscale

Scaled
Score

SEM

Descriptive
Term

SA

Section 3. Composite Performance
Composite

ER

PreBERS Strength Index

Subscale Scaled Scores
SR
SC
FI

___

___

___

Sum of
Scaled Scores

___

%ile
Rank

Descriptive
Term

______

____________

Strength
Index

Section 4. Other Pertinent Information

Who referred the student? _________________________________________________________________________
What was the reason for the referral? __________________________________________________________________
Parental permission obtained on (date) __________________________________________________________________
PreBERS results included in staffing or planning conference?

■

Yes

■

No

Section 5. Descriptive Terms
Scaled Score
Descriptive Term
Strength Index Score
© 2009 by PRO-ED, Inc.
1 2 3 4 5 6 7

1–3

4–5

6–7

8–12

13–14

15–16

17–20

Very Poor

Poor

Below Average

Average

Above Average

Superior

Very Superior

⬍70

70–79

80–89

90–110

111–120

121–130

⬎130

T DUPLIC
RIAL. DO NO
E
T
A
M
D
E
T
8 9CO10PYRIG
18 H17 16 15 14 13 12 11 10 09

ATE.

Additional copies of this form (#12847) may be purchased from
PRO-ED, 8700 Shoal Creek Blvd., Austin, TX 78757-6897
800/897-3202, Fax 800/397-7633, www.proedinc.com

Section 6. Response Form

not at all like the child

not much like the child

ER

SR

SC

FI

1. Demonstrates a sense of belonging to family

3

2

1

0

____

2. Trusts a significant person in his or her life

3

2

1

0

____

3. Understands the meaning of words similar to same-age peers

3

2

1

0

4. Is self-confident

3

2

1

0

____

3

2

1

0

____

3

2

1

0

3

2

1

0

8. Controls anger toward others

3

2

1

0

9. Carries on conversations

3

2

1

0

10. Expresses remorse for behavior that hurts others

3

2

1

0

____

SA

PL
E

Statement

like the child

very much like the child

Directions: The Preschool Behavioral and Emotional Rating Scale (PreBERS) contains a series of statements that are used to rate a preschool
child’s behaviors and emotions in a positive way. Read each statement and circle the number that corresponds to the rating that best describes the child’s status over the past 2 months. If the statement is very much like the child, circle the 3; if the statement is like the child,
circle the 2; if the statement is not much like the child, circle the 1; if the statement is not at all like the child, circle the 0. In making your
rating, it is important that you consider this child’s behavior in relation to other preschool children of similar age and gender. Rate each
statement to the best of your knowledge of the child.

11. Shows concern for the feelings of others

3

2

1

0

____

12. Interacts positively with parents

3

2

1

0

13. Reacts to disappointment calmly

3

2

1

0

14. Persists with tasks until completed

3

2

1

0

15. Stands up for self

3

2

1

0

16. Handles frustration with challenging tasks

3

2

1

0

17. Demonstrates age-appropriate hygiene skills

3

2

1

0

5. Acknowledges painful feelings
7. Asks for help

M

6. Maintains positive family relationships

Column subtotals

2

ED MATER
COPYRIGHT

IAL. DO NOT

DUPLICATE.

____

____
____

____
____

____
____
____
____
____
____

Statement

very much like the child

like the child

not much like the child

not at all like the child

ER

18. Takes turns in play situations

3

2

1

0

____

19. Is involved in family discussions

3

2

1

0

20. Accepts closeness and intimacy of others

3

2

1

0

____

21. Identifies own feelings

3

2

1

0

____

22. Makes friends

3

2

1

0

____

23. Accepts responsibility for own actions

3

2

1

0

2

1

0

3

2

1

0

3

2

1

0

3

2

1

0

____

3

2

1

0

____

3

2

1

0

3

2

1

0

3

2

1

0

____

32. Listens attentively when stories are read

3

2

1

0

____

33. Follows multistep directions

3

2

1

0

____

34. Is enthusiastic about life

3

2

1

0

35. Respects the rights of others

3

2

1

0

____

36. Shares with others

3

2

1

0

____

37. Apologizes to others when wrong

3

2

1

0

____

38. Retells stories or recent events

3

2

1

0

39. Is kind toward others

3

2

1

0

40. Uses details in talking with others

3

2

1

0

____

41. Works independently

3

2

1

0

____

42. Uses numbers and color words correctly

3

2

1

0

____

26. Asks others to play
27. Understands complex sentences
28. Listens to the conversation of others
29. Participates in family activities

SA

31. Pays attention to tasks

M

30. Accepts “no” for an answer

FI

____

3

25. Loses a game gracefully

SC

____

PL
E

24. Interacts positively with siblings

SR

____

____
____

____

____

____

____
____

Column subtotals
Previous page column subtotals
Total Raw Score
ED MATER
COPYRIGHT

IAL. DO NOT

DUPLICATE.
3

Section 7. Key Questions
1. What are the child’s favorite hobbies or activities? What does the child like to do?

2. What is the child’s favorite activity to do with the family?

3. What chores are the child’s responsibility in relationship to the family?

PL
E

4. How does the child react to disappointments or frustrations?

5. How does the child play or interact with peers?

6. At a time of need, to whom (e.g., parent, neighbor, friend, relative) would this family turn for support?

M

7. Describe the best things about this child.

SA

Section 8. Interpretations and Recommendations

4

ED MATER
COPYRIGHT

IAL. DO NOT

DUPLICATE.

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

MULTI-SECTOR SERVICE CONTACTS,
REVISED: Caregiver—Intake (MSSC–RC–I)
/

MSRDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

1 = Intake

MSRRESP (Respondent for interview)

1 = Caregiver (child’s caregiver in a family, household
environment)
3 = Youth without caregiver (independent youth)

MSRINTV (Who administered interview)

2 = Data collector

MSRMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

MSRLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Date last modified: September 2012

Multi-Sector Service Contacts, Revised:
Caregiver—Intake (MSSC–RC–I)

CHILD ID:

The next set of questions is about specific types of services (child’s name) and/or your family may have
received in the past 6 months. Some of the questions are about services that (child’s name) may have
received, while others are about services your family may have received related to (child’s name)’s care,
or services that (child’s name) and your family may both have received. These services may include
treatment received from a therapist or clinician such as individual therapy, or support such as respite
care, case management, or transportation.
Please keep in mind the various services your child and family have received from all the people,
organizations, and agencies involved with your child during the past 6 months. Services may include
those received through your child’s school, a child welfare agency, the police, or the courts. All of these
services and agencies are part of the service system in your community that works with children and
families.
1.

Within the past 6 months, has (child’s name) or your family received any services related to the
emotional or behavioral problems (child’s name) might have had? [NOTE TO INTERVIEWER:
Please show respondent the full list of services and the description of each service.]
1 = No
2 = Yes [GO TO QUESTION #7]
1a.

What was the reason that (child’s name) and/or your family did not receive any services?
1 = Completed services/discharged
2 = Decided not to continue services
3 = Did not need services
4 = Was not aware of any services or no services were offered
5 = Was not evaluated
6 = Problems with case managers (e.g., case managers not showing up or contacting
family)
7 = Ineligible for services
8 = Moved out of area and not received any services in the new area
9 = Child placed out of area (hospital, residential center, detention) and not received
any services in the new area
10 = Scheduling challenges
11 = Was evaluated, but waiting for assessment results
12 = Other—please specify __________________________

1b.

What was the last date (child’s name) and your family received any services?
__________________________
(mm/dd/yyyy)

[IF QUESTION #1a = 2, GO TO QUESTION #1c. OTHERWISE, END OF QUESTIONNAIRE.]
1c.

Why did your family decide not to continue services?
_________________________________________________________________________
_________________________________________________________________________

[IF NO SERVICES WERE RECEIVED IN THE PAST 6 MONTHS, END OF QUESTIONNAIRE.]

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
1

Multi-Sector Service Contacts, Revised:
Caregiver—Intake (MSSC–RC–I)

CHILD ID:

[NOTE TO INTERVIEWER: Questions #2–6 are skipped, as they are not applicable at intake.]

[CARD 1]
7.

What agencies were involved in providing services to (child’s name) and your family? [Select all
that apply]
1 = Mental health
2 = Education
3 = Social services/child welfare
4 = Juvenile justice
5 = Health
6 = Family court
7 = Other—please specify __________________________

[CARD 2]
8.

Please tell me if (child’s name) or your family received services in any of the following locations in
the past 6 months and whether these locations were convenient. [Select all that apply]
a.
Was the
location
convenient?

In the past 6
months, did you
receive services in
this location?

Service Location

No

Yes

No

Yes

1 = Mental health clinic or private practice

1

2

1

2

2 = School

1

2

1

2

3 = Juvenile court/probation

1

2

1

2

4 = Social services or child welfare offices

1

2

1

2

5 = Community location or service center (i.e.,
Boys’/Girls’ Clubs, YMCA, place of worship)

1

2

1

2

6 = Psychiatric hospital/psychiatric unit

1

2

1

2

7 = Medical hospital

1

2

1

2

8 = Home

1

2

1

2

9 = Non-hospital residential setting

1

2

1

2

10 = Jail/youth detention

1

2

1

2

1

2

1

2

11 = Other—please specify
________________________________________

[IF YES]

Now I’m going to ask you some questions about the specific services that (child’s name) or your family
received in the past 6 months. First, I’ll briefly describe a type of service to you, then I’ll ask whether or
not (child’s name) or your family received the service. If you received the service, I will ask you how
For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
2

Multi-Sector Service Contacts, Revised:
Caregiver—Intake (MSSC–RC–I)

CHILD ID:

often the service was received. Please try to estimate, to the best of your ability, the number of days you
received that service over the entire 6-month period. Remember that all of your answers will be kept
confidential.
Before we begin this set of questions, let’s review the 6-month timeline that we’ll be using. It is similar to
the one we have used with the other questionnaires.

[TIMELINE]
Since some of the following questions only apply to children who have had a problem with substance
abuse, I need to ask you about this again.
9.

In the past 6 months, has (child’s name) had a problem with substance abuse, including alcohol and
drugs?
1 = No [For Questions #10–35, do not ask questions in column “c”]
2 = Yes [For Questions #10–35, ask questions in all columns]

[NOTE TO INTERVIEWER: For each of the following questions (#10–35), read the brief description of
the service and site-specific names of the service. Then ask the respondent if this service was received in
the past 6 months. If it was received, continue with additional follow-up questions about this service. If
the service was not received, circle No and continue with the next service description. Only ask “c” if
caregiver answered “yes” to Question #9 (i.e., child had a problem with alcohol and drugs in the past 6
months), otherwise proceed to “d.”]

[CARD 3] [Service Definitions and Descriptions List]
b.
How well did the service
meet the needs of your
child and/or family?

12. Family preservation

For all variables and data elements:
Date last modified: December 2009

1 = No
2 = Yes

_____

1 = No
2 = Yes

[IF
YES]

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

666 = Not Applicable
777 = Refused

Extremely well

11b. Family advocacy and peer
support provided by
trained advocate

_____

Very well

11a. Mobile crisis outreach

1 = No
2 = Yes

Moderately well

11. Crisis stabilization

a.
On how
many
days?

Somewhat well

10. Assessment or evaluation

[IF
YES]

Not at all well

Service

In the past 6
months, did
your child
and/or your
family receive
this service?

c.
Was this
d.
service related
Did
you
to your child’s
pay at least
alcohol or
part of the
substance
costs
of this
abuse
service?
problem?

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

888 = Don’t Know
999 = Missing
3

Multi-Sector Service Contacts, Revised:
Caregiver—Intake (MSSC–RC–I)

CHILD ID:

b.
How well did the service
meet the needs of your
child and/or family?

_____

14. Group therapy

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

15. Individual therapy
16. Case management
17. Family therapy
18. Day treatment
19. Behavioral/therapeutic aide
20. Independent living
21. Youth transition
22. Caregiver or family support
23. Vocational training
24. Recreational activities

1 = No
2 = Yes

[IF
YES]

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

[IF
YES]

_____

1 = No
2 = Yes

_____

25. Afterschool programs or child
care

1 = No
2 = Yes

_____

26. Transportation

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

28. Residential therapeutic camp or
wilderness program

1 = No
2 = Yes

_____

29. Inpatient hospitalization

1 = No
2 = Yes

_____

27. Respite care

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

Extremely well

1 = No
2 = Yes

Very well

13. Medication treatment
monitoring

Moderately well

a.
On how
many
days?

Somewhat well

[IF
YES]

Not at all well

Service

In the past 6
months, did
your child
and/or your
family receive
this service?

c.
Was this
d.
service related
to your child’s Did you
pay at least
alcohol or
part of the
substance
costs of this
abuse
service?
problem?

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

888 = Don’t Know
999 = Missing
4

Multi-Sector Service Contacts, Revised:
Caregiver—Intake (MSSC–RC–I)

CHILD ID:

b.
How well did the service
meet the needs of your
child and/or family?

1 = No
2 = Yes

_____

1 = No
2 = Yes

[IF
YES]

_____

Extremely well

32. Therapeutic foster care

_____

Very well

31. Therapeutic group home

1 = No
2 = Yes

Moderately well

30. Residential treatment center

a.
On how
many
days?

Somewhat well

Service

[IF
YES]

Not at all well

In the past 6
months, did
your child
and/or your
family receive
this service?

c.
Was this
d.
service related
to your child’s Did you
pay at least
alcohol or
part of the
substance
costs of this
abuse
service?
problem?

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

33. Flexible funds

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

34. Informal support

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

35. School-based services

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

16e. [IF YES to Case management] How many case managers did you and your family have in the
past 6 months?
_____

[CARD 4]
33e. [IF YES to Flexible funds] What were the flexible funds used for? [Select all that apply]
1 = Housing
2 = Activities
3 = Utilities
4 = Supplies/groceries
5 = Clothing
6 = Furnishings/appliances
7 = Automobiles
8 = Transportation (contracted)
9 = Transportation (reimbursed)
10 = Incentive
11 = Medical
12 = Legal
13 = Other—please specify ____________________________________________

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
5

Multi-Sector Service Contacts, Revised:
Caregiver—Intake (MSSC–RC–I)

CHILD ID:

34e. [IF YES to Informal support] What types of informal support did you receive? [Select all that
apply]
1 = Emotional support (e.g., someone to listen to you, someone who knows what you
are going through)
2 = Physical support with caregiving tasks (e.g., babysitting, etc.)
3 = Financial support
4 = Transportation
5 = Informational support
6 = Other—please specify ____________________________________________
36.

[IF YES to any of 10d–35d] Thinking about the past 6 months, for all the services you indicated
above, what were your total out-of-pocket expenses in a typical month?
1 = < $50
2 = $51–$250
3 = $251–$500
4 = $501–$1,000
5 = > $1,000

The following questions ask things you might think are important in talking with your provider and about
what your provider actually talked about when you were first offered services for your child and you.
Please rate each statement indicating how important it is to you in your child’s and family’s service
experience.

[CARD 5]
Not at all Somewhat Moderately Very Extremely
important important important important important
How important is it to you to
37. have the services your child and you
receive explained to you before you begin
receiving them?

1

2

3

4

5

38. be informed about what improvements to
expect as a result of services?

1

2

3

4

5

39. be told about the research evidence that
shows that the services are effective?

1

2

3

4

5

40. be told about your provider’s experience
that shows how effective the services are
when used with families of children with
problems similar to your child’s?

1

2

3

4

5

41.

Did you and your child experience any of the following:
41a. Were the services explained to you before you received them?
1 = No
2 = Yes

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
6

Multi-Sector Service Contacts, Revised:
Caregiver—Intake (MSSC–RC–I)

CHILD ID:

41b. Were you informed about what improvements to expect?
1 = No
2 = Yes
41c. Were you told about the research evidence that shows that the services are effective?
1 = No
2 = Yes
41d. Were you told about your provider’s own experience with providing the services that has
shown how effective they are with families of children with problems similar to your child’s?
1 = No
2 = Yes
42.

At any time in the past 6 months, did you have a paid job (formal or informal), including selfemployment?
1 = No [END OF QUESTIONNAIRE]
2 = Yes

The next set of questions I am going to ask are about work during the past 6 months.

[CARD 6]
A little
Not at all
bit
43.

44.

45.

46.

47.

A
moderate Quite a A great
amount
bit
deal

To what extent have the services (child’s name)
or your family received helped you increase
your ability to do your job?

1

2

3

4

5

To what extent have the services (child’s name)
or your family received helped increase the
hours you are able to work?

1

2

3

4

5

To what extent have the services (child’s name)
or your family received helped increase the
money you have earned or increase your
income?

1

2

3

4

5

To what extent have the services (child’s name)
or your family received given you the
opportunity to develop more job-related skills?

1

2

3

4

5

To what extent do you think the services your
family has received have allowed you to gain
additional education or vocational skills?

1

2

3

4

5

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
7

Service Definitions and Descriptions
(To be used with the MSSC–RC questionnaire)

Generic Service Name
10. Assessment or evaluation

11. Crisis stabilization

11a. Mobile crisis outreach

11b. Family advocacy and peer
support provided by
trained advocate

12. Family preservation

Site-Specific
Service Name

Definitions and Descriptions
Assessment and evaluation services are used to determine
a child’s psychological, social, and behavioral strengths
and challenges. These are typically performed by a
psychologist or psychiatrist. Types of assessment may
include neurological, psychosocial, educational, and
vocational.
Crisis stabilization services are designed to stabilize a
child experiencing acute emotional or behavioral
difficulties. These services may include the development
of crisis plans, 24-hour telephone support, mobile
outreach, intensive in-home support during crisis, and
short-term emergency residential services.
Mobile crisis outreach services are provided by team
members (usually trained professionals holding either a
master’s level or bachelor’s level degree in the social
services field) who undergo intensive training in
counseling and crisis intervention skills and their
application. Teams respond rapidly to emergency requests
for services (usually within one hour of receiving a
request) wherever they are needed (like a person’s home,
schools, businesses or hospitals). Upon arrival, team
members will assess the situation, attempt to stabilize and
diffuse the crisis, provide counseling as needed, and
provide referrals to other resources. Typically, within 24
hours a team member will make a follow-up call with the
child and family to check on the child’s well-being.
Family advocacy services include speaking, acting or
writing with minimal conflict of interest on behalf of the
interests of child and family, in order to promote, protect
and defend the welfare of and justice for the child and
family by being on their side and no-one else’s, being
primarily concerned with their fundamental needs, and
remaining loyal and accountable to them in a way which is
empathic and vigorous. Peer support services include
caregivers who have coped with children with a variety of
problems (e.g., mental health and chronic illness) sharing
their experiences and offering support in various forms to
and caregivers who are coping with similar problems.
Those providing these services should be trained in their
roles as advocates and peer supports.
Family preservation services are designed to keep the
family together during difficult or stressful times. These
services may include 24-hour access to support services,
intensive in-home support during crisis when a child is at
risk of out-of-home placement or when the child is
returning from out-of-home placement. These are distinct
from crisis stabilization services as they may continue for
several months during transition or crisis.

Generic Service Name
13. Medication treatment
monitoring

14. Group therapy

15. Individual therapy

16. Case management

17. Family therapy

18. Day treatment

19. Behavioral/therapeutic aide

20. Independent living

21. Youth transition

Site-Specific
Service Name

Definitions and Descriptions
Medication treatment and monitoring services typically
include the prescription of psychoactive medications by a
physician (e.g., psychiatrist) that are designed to alleviate
symptoms and promote psychological growth. Treatment
includes periodic assessment and monitoring of the child’s
reaction(s) to the drug.
Group therapy relies on interaction among a group of
individuals, which could include children or children and
adults. Groups are typically facilitated by a therapist to
promote psychological and behavior change. Groups
typically meet together on a regular basis.
Individual therapy relies on interaction between
therapist/clinician and child to promote psychological and
behavior change.
Case management or service coordination involves finding
and organizing multiple treatment and support services,
and may also include preparing, monitoring, and revising
service plans; and advocating on behalf of the child and
family. Case managers may also provide supportive
counseling.
Family therapy involves a variety of family members such
as caregivers and/or siblings with or without the child
present. Interaction among family members is typically
facilitated by a therapist or counselor.
Day treatment consists of intensive, nonresidential
services that include an array of counseling, education,
and/or vocational training. These services involve a child
or youth for at least 5 hours a day, for at least 3 days a
week, and are offered in a variety of settings, including
schools, mental health centers, hospitals, or other
community locations.
Behavioral or therapeutic aide services are the supervision
of a child by trained adults in the home, the school, or
other community locations. The aide might provide
support and may assist with tutoring or recreational
activities.
Independent living services are designed to prepare older
adolescents to live independently and reduce their reliance
on the family or service system. These services may
include social and community living skills development
and peer support (e.g., look for job, pay bills, job skill
training, etc.).
Transition services are designed to help older adolescents
to move from the child system to the adult mental health
system.

Generic Service Name
22. Caregiver or family support

23. Vocational training

24. Recreational activities

25. Afterschool programs or child
care

26. Transportation

27. Respite care

28. Residential therapeutic camp or
wilderness program

29. Inpatient hospitalization

Site-Specific
Service Name

Definitions and Descriptions
Caregiver or family support services are provided to
caregivers or siblings (e.g., family activities, behavior
management training, parent classes, support groups,
individual therapy for caregiver or other family members).
Do not include recreational activities,
behavioral/therapeutic aide, transportation services, respite
care, afterschool activities or child care, which are
described in other questions.
Vocational training refers to the development life skills
and job skills designed to assist young adults with the
transition to independent living. (Parenting classes,
managing money, holding a job etc.)
Recreational activities are the use of community
recreation resources by the child that may include YMCA
or other physical fitness activities, youth sports programs,
karate classes, club memberships, summer camps, arts
activities, etc.
Regular afterschool programs and/or other types of child
care are commonly arranged so that the caregiver(s) can
work and/or attend school. Child care includes day care as
well as care during afterschool hours, evenings and/or
weekends. Afterschool programs may be recreational
and/or educational (e.g., supervised sports, tutoring, help
with homework) but their primary purpose is to provide
supervision of youths so that caregivers may work, attend
school, etc. Do not include respite, recreational activities,
behavioral or therapeutic aide, or caregiver/family support
services that are described in other questions.
Transportation services are transportation to appointments
(e.g., therapy sessions) and other scheduled mental health
services and activities, or reimbursement for public
transportation, van rentals, etc.
Respite care is a planned break for families wherein
trained parents or counselors assume the duties of
caregiving to allow the parent/caregivers a break. The
service may be provided in the child’s home or in other
community locations or in residential settings.
A residential therapeutic camp or wilderness program
involves children/youth and staff living together in a
wilderness or other camp environment often located
outside of the community. Treatment often focuses on
group process, and social skills development.
Inpatient hospitalization is the placement of child/youth in
a hospital for observation, evaluation, and/or treatment.
Services are usually medically oriented and may include
24-hour supervision; services may be used for short-term
treatment and crisis stabilization.

Generic Service Name
30. Residential treatment center

31. Therapeutic group home

32. Therapeutic foster care

33. Flexible funds

34. Informal support

35. School-based services

Site-Specific
Service Name

Definitions and Descriptions
A residential treatment center is a secure residential
facility that typically serves 10 or more children and youth
and provides 24-hour staff supervision, and may include
individual therapy, group therapy, family therapy,
behavior modification, skills development, education, and
recreational services. Lengths of stay tend to be longer in
residential treatment centers than in hospitals.
A therapeutic group home is a 24-hour residential
placement in a home-like setting with a relatively small
group of children with emotional and/or behavior
problems. Therapeutic care employs a variety of treatment
approaches and includes counseling, crisis support,
behavior management, and social and independent living
skills development.
A therapeutic foster home is a 24-hour residential
placement in a home with caregivers who are trained in
behavior management and social and independent living
skills development for children and youth with emotional
and behavioral problems.
Flexible funds are money for non-mental health service
items such as rent, utilities, or temporary living expenses
(e.g., clothes, food, bills, a special item, car repairs, etc.).
Informal support is defined as assistance from persons
who provide support to the child and family without
compensation from any formal service system. This type
of support includes asking a relative or friends to babysit a
child, support received from someone’s church, etc.
School-based services related to child’s emotional and
behavioral problems often include educational assessment
or testing; a self-contained special education classroom; a
resource room; a one-to-one classroom aide; and/or an
Individualized Education Plan (IEP).

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

MULTI-SECTOR SERVICE CONTACTS,
REVISED: Caregiver—Follow-Up (MSSC–RC–F)
/

MSRDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

MSRRESP (Respondent for interview)

1 = Caregiver (child’s caregiver in a family, household
environment)
3 = Youth without caregiver (independent youth)

MSRINTV (Who administered interview)

2 = Data collector

MSRMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

MSRLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Date last modified: September 2012

Multi-Sector Service Contacts, Revised:
Caregiver—Follow-Up (MSSC–RC–F)

CHILD ID:

The next set of questions is about specific types of services (child’s name) and/or your family may have
received in the past 6 months. Some of the questions are about services that (child’s name) may have
received, while others are about services your family may have received related to (child’s name)’s care,
or services that (child’s name) and your family may both have received. These services may include
treatment received from a therapist or clinician such as individual therapy, or support such as respite
care, case management, or transportation.
Please keep in mind the various services your child and family have received from all the people,
organizations, and agencies involved with your child during the past 6 months. Services may include
those received through your child’s school, a child welfare agency, the police, or the courts. All of these
services and agencies are part of the service system in your community that works with children and
families.
1.

Within the past 6 months, has (child’s name) or your family received any services related to the
emotional or behavioral problems (child’s name) might have had? [NOTE TO INTERVIEWER:
Please show respondent the full list of services and the description of each service.]
1 = No
2 = Yes [GO TO QUESTION #2]
1a.

What was the reason that (child’s name) and/or your family did not receive any services?
1 = Completed services/discharged
2 = Decided not to continue services
3 = Did not need services
4 = Was not aware of any services or no services were offered
5 = Was not evaluated
6 = Problems with case managers (e.g., case managers not showing up or contacting
family)
7 = Ineligible for services
8 = Moved out of area and not received any services in the new area
9 = Child placed out of area (hospital, residential center, detention) and not received
any services in the new area
10 = Scheduling challenges
11 = Was evaluated, but waiting for assessment results
12 = Other—please specify __________________________

1b.

What was the last date (child’s name) and your family received any services?
__________________________
(mm/dd/yyyy)

[IF QUESTION #1a = 2, GO TO QUESTION #1c. OTHERWISE, END OF QUESTIONNAIRE.]
1c.

Why did your family decide not to continue services?
_________________________________________________________________________
_________________________________________________________________________

[IF NO SERVICES WERE RECEIVED IN THE PAST 6 MONTHS, END OF QUESTIONNAIRE.]

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
1

Multi-Sector Service Contacts, Revised:
Caregiver—Follow-Up (MSSC–RC–F)

CHILD ID:

2.

In the past 6 months, did (child’s name) or your family receive services under (site’s specific name
for the system of care)?
1 = No [GO TO QUESTION #5]
2 = Yes
2a.

Did (child’s name) and your family receive wraparound services? By wraparound, we mean a
process through which providers collaborate with your family to develop an integrated and
creative service plan tailored to the strengths and specific needs of your child and family
using a team that includes your family, teachers, clinicians, friends, and a facilitator to
coordinate the process. Services are “wrapped around” your child and family in your home,
school, and community rather than less accessible or more restrictive places (like the
provider’s office or a residential treatment center).
1 = No
2 = Yes

2b.

Did (child’s name) and your family have a youth and family team?
1 = No
2 = Yes

[CARD 1]
Absolutely Probably
not
not
Not sure Probably Absolutely
3.

4.

5.

Based on your experience with (site’s
specific name for the system of care) in the
past 6 months, if your child and family
needed help again, would you come back to
the program?

1

2

3

4

5

Based on your experience with (site’s
specific name for the system of care) in the
past 6 months, if you have friends whose
family or child needed similar help, would
you recommend the program to them?

1

2

3

4

5

In the past 6 months, did (child’s name) or your family receive services provided in your
community under any other programs, for example, (site’s specific name[s] for programs other
than the system of care)?
1 = No
2 = Yes

[NOTE TO INTERVIEWER: Clarify that these are services asked about in MSSC–RC.]
6.

In the past 6 months, did (child’s name) or your family receive services provided outside your
community under any other programs, for example, (site’s specific name[s] for programs other
than the system of care)?
1 = No
2 = Yes

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
2

Multi-Sector Service Contacts, Revised:
Caregiver—Follow-Up (MSSC–RC–F)

CHILD ID:

[CARD 2]
7.

What agencies were involved in providing services to (child’s name) and your family? [Select all
that apply]
1 = Mental health
2 = Education
3 = Social services/child welfare
4 = Juvenile justice
5 = Health
6 = Family court
7 = Other—please specify __________________________

[CARD 3]
8.

Please tell me if (child’s name) or your family received services in any of the following locations in
the past 6 months and whether these locations were convenient. [Select all that apply]
In the past 6
months, did you
receive services in
this location?

Service Location

a.
Was the
location
convenient?

No

Yes

No

Yes

1 = Mental health clinic or private practice

1

2

1

2

2 = School

1

2

1

2

3 = Juvenile court/probation

1

2

1

2

4 = Social services or child welfare offices

1

2

1

2

5 = Community location or service center (i.e.,
Boys’/Girls’ Clubs, YMCA, place of worship)

1

2

1

2

6 = Psychiatric hospital/psychiatric unit

1

2

1

2

7 = Medical hospital

1

2

1

2

8 = Home

1

2

1

2

9 = Non-hospital residential setting

1

2

1

2

10 = Jail/youth detention

1

2

1

2

1

2

1

2

11 = Other—please specify
________________________________________

[IF YES]

Now I’m going to ask you some questions about the specific services that (child’s name) or your family
received in the past 6 months. First, I’ll briefly describe a type of service to you, then I’ll ask whether or
not (child’s name) or your family received the service. If you received the service, I will ask you how
often the service was received. Please try to estimate, to the best of your ability, the number of days you
For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
3

Multi-Sector Service Contacts, Revised:
Caregiver—Follow-Up (MSSC–RC–F)

CHILD ID:

received that service over the entire 6-month period. Remember that all of your answers will be kept
confidential.
Before we begin this set of questions, let’s review the 6-month timeline that we’ll be using. It is similar to
the one we have used with the other questionnaires.

[TIMELINE]
Since some of the following questions only apply to children who have had a problem with substance
abuse, I need to ask you about this again.
9.

In the past 6 months, has (child’s name) had a problem with substance abuse, including alcohol and
drugs?
1 = No [For Questions #10–35, do not ask questions in column “c”]
2 = Yes [For Questions #10–35, ask questions in all columns]

[NOTE TO INTERVIEWER: For each of the following questions (#10–35), read the brief description of
the service and site-specific names of the service. Then ask the respondent if this service was received in
the past 6 months. If it was received, continue with additional follow-up questions about this service. If
the service was not received, circle No and continue with the next service description. Only ask “c” if
caregiver answered “yes” to Question #9 (i.e., child had a problem with alcohol and drugs in the past 6
months), otherwise proceed to “d.”]

[CARD 4] [Service Definitions and Descriptions List]
b.
How well did the service
meet the needs of your
child and/or family?

12. Family preservation

For all variables and data elements:
Date last modified: December 2009

1 = No
2 = Yes

_____

1 = No
2 = Yes

[IF
YES]

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

666 = Not Applicable
777 = Refused

Extremely well

11b. Family advocacy and peer
support provided by
trained advocate

_____

Very well

11a. Mobile crisis outreach

1 = No
2 = Yes

Moderately well

11. Crisis stabilization

a.
On how
many
days?

Somewhat well

10. Assessment or evaluation

[IF
YES]

Not at all well

Service

In the past 6
months, did
your child
and/or your
family receive
this service?

c.
Was this
d.
service related
Did
you
to your child’s
pay at least
alcohol or
part of the
substance
costs of this
abuse
service?
problem?

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

888 = Don’t Know
999 = Missing
4

Multi-Sector Service Contacts, Revised:
Caregiver—Follow-Up (MSSC–RC–F)

CHILD ID:

b.
How well did the service
meet the needs of your
child and/or family?

_____

14. Group therapy

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

15. Individual therapy
16. Case management
17. Family therapy
18. Day treatment
19. Behavioral/therapeutic aide
20. Independent living
21. Youth transition
22. Caregiver or family support
23. Vocational training
24. Recreational activities

1 = No
2 = Yes

[IF
YES]

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

[IF
YES]

_____

1 = No
2 = Yes

_____

25. Afterschool programs or child
care

1 = No
2 = Yes

_____

26. Transportation

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

28. Residential therapeutic camp or
wilderness program

1 = No
2 = Yes

_____

29. Inpatient hospitalization

1 = No
2 = Yes

_____

27. Respite care

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

Extremely well

1 = No
2 = Yes

Very well

13. Medication treatment
monitoring

Moderately well

a.
On how
many
days?

Somewhat well

[IF
YES]

Not at all well

Service

In the past 6
months, did
your child
and/or your
family receive
this service?

c.
Was this
d.
service related
to your child’s Did you
pay at least
alcohol or
part of the
substance
costs of this
abuse
service?
problem?

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

888 = Don’t Know
999 = Missing
5

Multi-Sector Service Contacts, Revised:
Caregiver—Follow-Up (MSSC–RC–F)

CHILD ID:

b.
How well did the service
meet the needs of your
child and/or family?

1 = No
2 = Yes

_____

1 = No
2 = Yes

[IF
YES]

_____

Extremely well

32. Therapeutic foster care

_____

Very well

31. Therapeutic group home

1 = No
2 = Yes

Moderately well

30. Residential treatment center

a.
On how
many
days?

Somewhat well

Service

[IF
YES]

Not at all well

In the past 6
months, did
your child
and/or your
family receive
this service?

c.
Was this
d.
service related
to your child’s Did you
pay at least
alcohol or
part of the
substance
costs of this
abuse
service?
problem?

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

33. Flexible funds

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

34. Informal support

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

35. School-based services

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

16e. [IF YES to Case management] How many case managers did you and your family have in the
past 6 months?
_____

[CARD 5]
33e. [IF YES to Flexible funds] What were the flexible funds used for? [Select all that apply]
1 = Housing
2 = Activities
3 = Utilities
4 = Supplies/groceries
5 = Clothing
6 = Furnishings/appliances
7 = Automobiles
8 = Transportation (contracted)
9 = Transportation (reimbursed)
10 = Incentive
11 = Medical
12 = Legal
13 = Other—please specify ____________________________________________

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
6

Multi-Sector Service Contacts, Revised:
Caregiver—Follow-Up (MSSC–RC–F)

CHILD ID:

34e. [IF YES to Informal support] What types of informal support did you receive? [Select all that
apply]
1 = Emotional support (e.g., someone to listen to you, someone who knows what you
are going through)
2 = Physical support with caregiving tasks (e.g., babysitting, etc.)
3 = Financial support
4 = Transportation
5 = Informational support
6 = Other—please specify ____________________________________________
36.

[IF YES to any of 10d–35d] Thinking about the past 6 months, for all the services you indicated
above, what were your total out-of-pocket expenses in a typical month?
1 = < $50
2 = $51–$250
3 = $251–$500
4 = $501–$1,000
5 = > $1,000

The following questions ask things you might think are important in talking with your provider and about
what your provider actually talked about when you were first offered services for your child and you.
Please rate each statement indicating how important it is to you in your child’s and family’s service
experience.

[CARD 6]
Not at all Somewhat Moderately Very Extremely
important important important important important
How important is it to you to . . .
37. have the services your child and you
receive explained to you before you begin
receiving them?

1

2

3

4

5

38. be informed about what improvements to
expect as a result of services?

1

2

3

4

5

39. be told about the research evidence that
shows that the services are effective?

1

2

3

4

5

40. be told about your provider’s experience
that shows how effective the services are
when used with families of children with
problems similar to your child’s?

1

2

3

4

5

41.

Did you and your child experience any of the following:
41a. Were the services explained to you before you received them?
1 = No
2 = Yes

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
7

Multi-Sector Service Contacts, Revised:
Caregiver—Follow-Up (MSSC–RC–F)

CHILD ID:

41b. Were you informed about what improvements to expect?
1 = No
2 = Yes
41c. Were you told about the research evidence that shows that the services are effective?
1 = No
2 = Yes
41d. Were you told about your provider’s own experience with providing the services that has
shown how effective they are with families of children with problems similar to your child’s?
1 = No
2 = Yes
42.

At any time in the past 6 months, did you have a paid job (formal or informal), including selfemployment?
1 = No [END OF QUESTIONNAIRE]
2 = Yes

The next set of questions I am going to ask are about work during the past 6 months.

[CARD 7]
A little
Not at all
bit
43.

44.

45.

46.

47.

A
moderate Quite a A great
amount
bit
deal

To what extent have the services (child’s name)
or your family received helped you increase
your ability to do your job?

1

2

3

4

5

To what extent have the services (child’s name)
or your family received helped increase the
hours you are able to work?

1

2

3

4

5

To what extent have the services (child’s name)
or your family received helped increase the
money you have earned or increase your
income?

1

2

3

4

5

To what extent have the services (child’s name)
or your family received given you the
opportunity to develop more job-related skills?

1

2

3

4

5

To what extent do you think the services your
family has received have allowed you to gain
additional education or vocational skills?

1

2

3

4

5

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
8

Service Definitions and Descriptions
(To be used with the MSSC–RC questionnaire)

Generic Service Name
10. Assessment or evaluation

11. Crisis stabilization

11a. Mobile crisis outreach

11b. Family advocacy and peer
support provided by
trained advocate

12. Family preservation

Site-Specific
Service Name

Definitions and Descriptions
Assessment and evaluation services are used to determine
a child’s psychological, social, and behavioral strengths
and challenges. These are typically performed by a
psychologist or psychiatrist. Types of assessment may
include neurological, psychosocial, educational, and
vocational.
Crisis stabilization services are designed to stabilize a
child experiencing acute emotional or behavioral
difficulties. These services may include the development
of crisis plans, 24-hour telephone support, mobile
outreach, intensive in-home support during crisis, and
short-term emergency residential services.
Mobile crisis outreach services are provided by team
members (usually trained professionals holding either a
master’s level or bachelor’s level degree in the social
services field) who undergo intensive training in
counseling and crisis intervention skills and their
application. Teams respond rapidly to emergency requests
for services (usually within one hour of receiving a
request) wherever they are needed (like a person’s home,
schools, businesses or hospitals). Upon arrival, team
members will assess the situation, attempt to stabilize and
diffuse the crisis, provide counseling as needed, and
provide referrals to other resources. Typically, within 24
hours a team member will make a follow-up call with the
child and family to check on the child’s well-being.
Family advocacy services include speaking, acting or
writing with minimal conflict of interest on behalf of the
interests of child and family, in order to promote, protect
and defend the welfare of and justice for the child and
family by being on their side and no-one else’s, being
primarily concerned with their fundamental needs, and
remaining loyal and accountable to them in a way which is
empathic and vigorous. Peer support services include
caregivers who have coped with children with a variety of
problems (e.g., mental health and chronic illness) sharing
their experiences and offering support in various forms to
and caregivers who are coping with similar problems.
Those providing these services should be trained in their
roles as advocates and peer supports.
Family preservation services are designed to keep the
family together during difficult or stressful times. These
services may include 24-hour access to support services,
intensive in-home support during crisis when a child is at
risk of out-of-home placement or when the child is
returning from out-of-home placement. These are distinct
from crisis stabilization services as they may continue for
several months during transition or crisis.

Generic Service Name
13. Medication treatment
monitoring

14. Group therapy

15. Individual therapy

16. Case management

17. Family therapy

18. Day treatment

19. Behavioral/therapeutic aide

20. Independent living

21. Youth transition

Site-Specific
Service Name

Definitions and Descriptions
Medication treatment and monitoring services typically
include the prescription of psychoactive medications by a
physician (e.g., psychiatrist) that are designed to alleviate
symptoms and promote psychological growth. Treatment
includes periodic assessment and monitoring of the child’s
reaction(s) to the drug.
Group therapy relies on interaction among a group of
individuals, which could include children or children and
adults. Groups are typically facilitated by a therapist to
promote psychological and behavior change. Groups
typically meet together on a regular basis.
Individual therapy relies on interaction between
therapist/clinician and child to promote psychological and
behavior change.
Case management or service coordination involves finding
and organizing multiple treatment and support services,
and may also include preparing, monitoring, and revising
service plans; and advocating on behalf of the child and
family. Case managers may also provide supportive
counseling.
Family therapy involves a variety of family members such
as caregivers and/or siblings with or without the child
present. Interaction among family members is typically
facilitated by a therapist or counselor.
Day treatment consists of intensive, nonresidential
services that include an array of counseling, education,
and/or vocational training. These services involve a child
or youth for at least 5 hours a day, for at least 3 days a
week, and are offered in a variety of settings, including
schools, mental health centers, hospitals, or other
community locations.
Behavioral or therapeutic aide services are the supervision
of a child by trained adults in the home, the school, or
other community locations. The aide might provide
support and may assist with tutoring or recreational
activities.
Independent living services are designed to prepare older
adolescents to live independently and reduce their reliance
on the family or service system. These services may
include social and community living skills development
and peer support (e.g., look for job, pay bills, job skill
training, etc.).
Transition services are designed to help older adolescents
to move from the child system to the adult mental health
system.

Generic Service Name
22. Caregiver or family support

23. Vocational training

24. Recreational activities

25. Afterschool programs or child
care

26. Transportation

27. Respite care

28. Residential therapeutic camp or
wilderness program

29. Inpatient hospitalization

Site-Specific
Service Name

Definitions and Descriptions
Caregiver or family support services are provided to
caregivers or siblings (e.g., family activities, behavior
management training, parent classes, support groups,
individual therapy for caregiver or other family members).
Do not include recreational activities,
behavioral/therapeutic aide, transportation services, respite
care, afterschool activities or child care, which are
described in other questions.
Vocational training refers to the development life skills
and job skills designed to assist young adults with the
transition to independent living. (Parenting classes,
managing money, holding a job etc.)
Recreational activities are the use of community
recreation resources by the child that may include YMCA
or other physical fitness activities, youth sports programs,
karate classes, club memberships, summer camps, arts
activities, etc.
Regular afterschool programs and/or other types of child
care are commonly arranged so that the caregiver(s) can
work and/or attend school. Child care includes day care as
well as care during afterschool hours, evenings and/or
weekends. Afterschool programs may be recreational
and/or educational (e.g., supervised sports, tutoring, help
with homework) but their primary purpose is to provide
supervision of youths so that caregivers may work, attend
school, etc. Do not include respite, recreational activities,
behavioral or therapeutic aide, or caregiver/family support
services that are described in other questions.
Transportation services are transportation to appointments
(e.g., therapy sessions) and other scheduled mental health
services and activities, or reimbursement for public
transportation, van rentals, etc.
Respite care is a planned break for families wherein
trained parents or counselors assume the duties of
caregiving to allow the parent/caregivers a break. The
service may be provided in the child’s home or in other
community locations or in residential settings.
A residential therapeutic camp or wilderness program
involves children/youth and staff living together in a
wilderness or other camp environment often located
outside of the community. Treatment often focuses on
group process, and social skills development.
Inpatient hospitalization is the placement of child/youth in
a hospital for observation, evaluation, and/or treatment.
Services are usually medically oriented and may include
24-hour supervision; services may be used for short-term
treatment and crisis stabilization.

Generic Service Name
30. Residential treatment center

31. Therapeutic group home

32. Therapeutic foster care

33. Flexible funds

34. Informal support

35. School-based services

Site-Specific
Service Name

Definitions and Descriptions
A residential treatment center is a secure residential
facility that typically serves 10 or more children and youth
and provides 24-hour staff supervision, and may include
individual therapy, group therapy, family therapy,
behavior modification, skills development, education, and
recreational services. Lengths of stay tend to be longer in
residential treatment centers than in hospitals.
A therapeutic group home is a 24-hour residential
placement in a home-like setting with a relatively small
group of children with emotional and/or behavior
problems. Therapeutic care employs a variety of treatment
approaches and includes counseling, crisis support,
behavior management, and social and independent living
skills development.
A therapeutic foster home is a 24-hour residential
placement in a home with caregivers who are trained in
behavior management and social and independent living
skills development for children and youth with emotional
and behavioral problems.
Flexible funds are money for non-mental health service
items such as rent, utilities, or temporary living expenses
(e.g., clothes, food, bills, a special item, car repairs, etc.).
Informal support is defined as assistance from persons
who provide support to the child and family without
compensation from any formal service system. This type
of support includes asking a relative or friends to babysit a
child, support received from someone’s church, etc.
School-based services related to child’s emotional and
behavioral problems often include educational assessment
or testing; a self-contained special education classroom; a
resource room; a one-to-one classroom aide; and/or an
Individualized Education Plan (IEP).

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

MULTI-SECTOR SERVICE CONTACTS,
REVISED: Staff as Caregiver—Intake
(MSSC–RS–I)
/

MSRDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

1 = Intake

MSRRESP (Respondent for interview)

2 = Staff as Caregiver (staffperson who has acted as the
child’s day-to-day caregiver for the majority of the past 6
months)

MSRINTV (Who administered interview)

2 = Data collector

MSRMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

MSRLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Date last modified: September 2012

Multi-Sector Service Contacts, Revised:
Staff as Caregiver—Intake (MSSC–RS–I)

CHILD ID:

The next set of questions is about specific types of services (child’s name) and/or his/her family may have
received in the past 6 months. Some of the questions are about services that (child’s name) may have
received, while others are about services his/her family may have received related to (child’s name)’s
care, or services that (child’s name) and his/her family may both have received. These services may
include treatment received from a therapist or clinician such as individual therapy, or support such as
respite care, case management, or transportation.
Please keep in mind the various services (child’s name) and his/her family have received from all the
people, organizations, and agencies involved with (child’s name) during the past 6 months. Services may
include those received through (child’s name)’s school, a child welfare agency, the police, or the courts.
All of these services and agencies are part of the service system in your community that works with
children and families.
1.

Within the past 6 months, has (child’s name) or his/her family received any services related to the
emotional or behavioral problems (child’s name) might have had? [NOTE TO INTERVIEWER:
Please show respondent the full list of services and the description of each service.]
1 = No
2 = Yes [GO TO QUESTION #7]
1a.

What was the reason that (child’s name) and/or his/her family did not receive any services?
1 = Completed services/discharged
2 = Decided not to continue services
3 = Did not need services
4 = Was not aware of any services or no services were offered
5 = Was not evaluated
6 = Problems with case managers (e.g., case managers not showing up or contacting
family)
7 = Ineligible for services
8 = Moved out of area and not received any services in the new area
9 = Child placed out of area (hospital, residential center, detention) and not received
any services in the new area
10 = Scheduling challenges
11 = Was evaluated, but waiting for assessment results
12 = Other—please specify __________________________

1b.

What was the last date (child’s name) and his/her family received any services?
__________________________
(mm/dd/yyyy)

[IF QUESTION #1a = 2, GO TO QUESTION #1c. OTHERWISE, END OF QUESTIONNAIRE.]
1c.

Why did (child’s name)’s family decide not to continue services?
_________________________________________________________________________
_________________________________________________________________________

[IF NO SERVICES WERE RECEIVED IN THE PAST 6 MONTHS, END OF QUESTIONNAIRE.]

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
1

Multi-Sector Service Contacts, Revised:
Staff as Caregiver—Intake (MSSC–RS–I)

CHILD ID:

[NOTE TO INTERVIEWER: Questions #2–6 are skipped, as they are not applicable at intake.]

[CARD 1]
7.

What agencies were involved in providing services to (child’s name) and his/her family? [Select all
that apply]
1 = Mental health
2 = Education
3 = Social services/child welfare
4 = Juvenile justice
5 = Health
6 = Family court
7 = Other—please specify __________________________

[CARD 2]
8.

Please tell me if (child’s name) or his/her family received services in any of the following locations
in the past 6 months and whether these locations were convenient. [Select all that apply]
In the past 6
months, did
(child’s name) or
his/her family
receive services in
this location?

Service Location

a.
Was the
location
convenient?

No

Yes

No

Yes

1 = Mental health clinic or private practice

1

2

1

2

2 = School

1

2

1

2

3 = Juvenile court/probation

1

2

1

2

4 = Social services or child welfare offices

1

2

1

2

5 = Community location or service center (i.e.,
Boys’/Girls’ Clubs, YMCA, place of worship)

1

2

1

2

6 = Psychiatric hospital/psychiatric unit

1

2

1

2

7 = Medical hospital

1

2

1

2

8 = Home

1

2

1

2

9 = Non-hospital residential setting

1

2

1

2

10 = Jail/youth detention

1

2

1

2

1

2

1

2

11 = Other—please specify
________________________________________

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

[IF YES]

888 = Don’t Know
999 = Missing
2

Multi-Sector Service Contacts, Revised:
Staff as Caregiver—Intake (MSSC–RS–I)

CHILD ID:

Now I’m going to ask you some questions about the specific services that (child’s name) or his/her family
received in the past 6 months. First, I’ll briefly describe a type of service to you, then I’ll ask whether or
not (child’s name) or his/her family received the service. If they received the service, I will ask you how
often the service was received. Please try to estimate, to the best of your ability, the number of days they
received that service over the entire 6-month period. Remember that all of your answers will be kept
confidential.
Before we begin this set of questions, let’s review the 6-month timeline that we’ll be using. It is similar to
the one we have used with the other questionnaires.

[TIMELINE]
Since some of the following questions only apply to children who have had a problem with substance
abuse, I need to ask you about this again.
9.

In the past 6 months, has (child’s name) had a problem with substance abuse, including alcohol and
drugs?
1 = No [For Questions #10–35, do not ask questions in column “c”]
2 = Yes [For Questions #10–35, ask questions in all columns]

[NOTE TO INTERVIEWER: For each of the following questions (#10–35), read the brief description of
the service and site-specific names of the service. Then ask the respondent if this service was received in
the past 6 months. If it was received, continue with additional follow-up questions about this service. If
the service was not received, circle No and continue with the next service description. Only ask “c” if
respondent answered “yes” to Question #9 (i.e., child had a problem with alcohol and drugs in the past 6
months), otherwise proceed to “d.”]

[CARD 3] [Service Definitions and Descriptions List]
b.
How well did the service
meet the needs of (child’s
name) and/or his/her
family?

For all variables and data elements:
Date last modified: December 2009

1 = No
2 = Yes

_____

1 = No
2 = Yes

[IF
YES]

_____

666 = Not Applicable
777 = Refused

Extremely well

_____

Very well

11a. Mobile crisis outreach

1 = No
2 = Yes

Moderately well

11. Crisis stabilization

a.
On how
many
days?

Somewhat well

10. Assessment or evaluation

[IF
YES]

d.
Did (child’s
name)’s
family pay
at least part
of the costs
of this
service?

Not at all well

Service

In the past 6
months, did
(child’s name)
and/or his/her
family receive
this service?

c.
Was this
service related
to (child’s
name)’s
alcohol or
substance
abuse
problem?

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

888 = Don’t Know
999 = Missing
3

Multi-Sector Service Contacts, Revised:
Staff as Caregiver—Intake (MSSC–RS–I)

CHILD ID:

b.
How well did the service
meet the needs of (child’s
name) and/or his/her
family?

1 = No
2 = Yes

_____

13. Medication treatment
monitoring

1 = No
2 = Yes

_____

14. Group therapy

1 = No
2 = Yes

_____

12. Family preservation

15. Individual therapy
16. Case management
17. Family therapy
18. Day treatment
19. Behavioral/therapeutic aide
20. Independent living
21. Youth transition
22. Caregiver or family support
23. Vocational training
24. Recreational activities

1 = No
2 = Yes

[IF
YES]

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

[IF
YES]

_____

1 = No
2 = Yes

_____

25. Afterschool programs or child
care

1 = No
2 = Yes

_____

26. Transportation

1 = No
2 = Yes

_____

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

Extremely well

_____

Very well

1 = No
2 = Yes

Moderately well

a.
On how
many
days?

Somewhat well

11b. Family advocacy and peer
support provided by
trained advocate

[IF
YES]

d.
Did (child’s
name)’s
family pay
at least part
of the costs
of this
service?

Not at all well

Service

In the past 6
months, did
(child’s name)
and/or his/her
family receive
this service?

c.
Was this
service related
to (child’s
name)’s
alcohol or
substance
abuse
problem?

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

888 = Don’t Know
999 = Missing
4

Multi-Sector Service Contacts, Revised:
Staff as Caregiver—Intake (MSSC–RS–I)

CHILD ID:

b.
How well did the service
meet the needs of (child’s
name) and/or his/her
family?

28. Residential therapeutic camp or
wilderness program

1 = No
2 = Yes

_____

29. Inpatient hospitalization

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

30. Residential treatment center
31. Therapeutic group home
32. Therapeutic foster care

1 = No
2 = Yes
1 = No
2 = Yes

[IF
YES]

_____
_____

Extremely well

_____

Very well

1 = No
2 = Yes

Moderately well

27. Respite care

a.
On how
many
days?

Somewhat well

Service

[IF
YES]

d.
Did (child’s
name)’s
family pay
at least part
of the costs
of this
service?

Not at all well

In the past 6
months, did
(child’s name)
and/or his/her
family receive
this service?

c.
Was this
service related
to (child’s
name)’s
alcohol or
substance
abuse
problem?

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

33. Flexible funds

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

34. Informal support

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

35. School-based services

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

16e. [IF YES to Case management] How many case managers did (child’s name) and his/her
family have in the past 6 months?
_____

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
5

Multi-Sector Service Contacts, Revised:
Staff as Caregiver—Intake (MSSC–RS–I)

CHILD ID:

[CARD 4]
33e. [IF YES to Flexible funds] What were the flexible funds used for? [Select all that apply]
1 = Housing
2 = Activities
3 = Utilities
4 = Supplies/groceries
5 = Clothing
6 = Furnishings/appliances
7 = Automobiles
8 = Transportation (contracted)
9 = Transportation (reimbursed)
10 = Incentive
11 = Medical
12 = Legal
13 = Other—please specify ____________________________________________
34e. [IF YES to Informal support] What types of informal support did (child’s name)’s family
receive? [Select all that apply]
1 = Emotional support (e.g., someone to listen to you, someone who knows what you
are going through)
2 = Physical support with caregiving tasks (e.g., babysitting, etc.)
3 = Financial support
4 = Transportation
5 = Informational support
6 = Other—please specify ____________________________________________
[NOTE TO INTERVIEWER: Questions #36–47 are skipped for “staff as caregiver,” as they are not
applicable for this respondent.]

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
6

Service Definitions and Descriptions
(To be used with the MSSC–RS questionnaire)

Generic Service Name
10. Assessment or evaluation

11. Crisis stabilization

11a. Mobile crisis outreach

11b. Family advocacy and peer
support provided by
trained advocate

12. Family preservation

Site-Specific
Service Name

Definitions and Descriptions
Assessment and evaluation services are used to determine
a child’s psychological, social, and behavioral strengths
and challenges. These are typically performed by a
psychologist or psychiatrist. Types of assessment may
include neurological, psychosocial, educational, and
vocational.
Crisis stabilization services are designed to stabilize a
child experiencing acute emotional or behavioral
difficulties. These services may include the development
of crisis plans, 24-hour telephone support, mobile
outreach, intensive in-home support during crisis, and
short-term emergency residential services.
Mobile crisis outreach services are provided by team
members (usually trained professionals holding either a
master’s level or bachelor’s level degree in the social
services field) who undergo intensive training in
counseling and crisis intervention skills and their
application. Teams respond rapidly to emergency requests
for services (usually within one hour of receiving a
request) wherever they are needed (like a person’s home,
schools, businesses or hospitals). Upon arrival, team
members will assess the situation, attempt to stabilize and
diffuse the crisis, provide counseling as needed, and
provide referrals to other resources. Typically, within 24
hours a team member will make a follow-up call with the
child and family to check on the child’s well-being.
Family advocacy services include speaking, acting or
writing with minimal conflict of interest on behalf of the
interests of child and family, in order to promote, protect
and defend the welfare of and justice for the child and
family by being on their side and no-one else’s, being
primarily concerned with their fundamental needs, and
remaining loyal and accountable to them in a way which is
empathic and vigorous. Peer support services include
caregivers who have coped with children with a variety of
problems (e.g., mental health and chronic illness) sharing
their experiences and offering support in various forms to
and caregivers who are coping with similar problems.
Those providing these services should be trained in their
roles as advocates and peer supports.
Family preservation services are designed to keep the
family together during difficult or stressful times. These
services may include 24-hour access to support services,
intensive in-home support during crisis when a child is at
risk of out-of-home placement or when the child is
returning from out-of-home placement. These are distinct
from crisis stabilization services as they may continue for
several months during transition or crisis.

Generic Service Name
13. Medication treatment
monitoring

14. Group therapy

15. Individual therapy

16. Case management

17. Family therapy

18. Day treatment

19. Behavioral/therapeutic aide

20. Independent living

21. Youth transition

Site-Specific
Service Name

Definitions and Descriptions
Medication treatment and monitoring services typically
include the prescription of psychoactive medications by a
physician (e.g., psychiatrist) that are designed to alleviate
symptoms and promote psychological growth. Treatment
includes periodic assessment and monitoring of the child’s
reaction(s) to the drug.
Group therapy relies on interaction among a group of
individuals, which could include children or children and
adults. Groups are typically facilitated by a therapist to
promote psychological and behavior change. Groups
typically meet together on a regular basis.
Individual therapy relies on interaction between
therapist/clinician and child to promote psychological and
behavior change.
Case management or service coordination involves finding
and organizing multiple treatment and support services,
and may also include preparing, monitoring, and revising
service plans; and advocating on behalf of the child and
family. Case managers may also provide supportive
counseling.
Family therapy involves a variety of family members such
as caregivers and/or siblings with or without the child
present. Interaction among family members is typically
facilitated by a therapist or counselor.
Day treatment consists of intensive, nonresidential
services that include an array of counseling, education,
and/or vocational training. These services involve a child
or youth for at least 5 hours a day, for at least 3 days a
week, and are offered in a variety of settings, including
schools, mental health centers, hospitals, or other
community locations.
Behavioral or therapeutic aide services are the supervision
of a child by trained adults in the home, the school, or
other community locations. The aide might provide
support and may assist with tutoring or recreational
activities.
Independent living services are designed to prepare older
adolescents to live independently and reduce their reliance
on the family or service system. These services may
include social and community living skills development
and peer support (e.g., look for job, pay bills, job skill
training, etc.).
Transition services are designed to help older adolescents
to move from the child system to the adult mental health
system.

Generic Service Name
22. Caregiver or family support

23. Vocational training

24. Recreational activities

25. Afterschool programs or child
care

26. Transportation

27. Respite care

28. Residential therapeutic camp or
wilderness program

29. Inpatient hospitalization

Site-Specific
Service Name

Definitions and Descriptions
Caregiver or family support services are provided to
caregivers or siblings (e.g., family activities, behavior
management training, parent classes, support groups,
individual therapy for caregiver or other family members).
Do not include recreational activities,
behavioral/therapeutic aide, transportation services, respite
care, afterschool activities or child care, which are
described in other questions.
Vocational training refers to the development life skills
and job skills designed to assist young adults with the
transition to independent living. (Parenting classes,
managing money, holding a job etc.)
Recreational activities are the use of community
recreation resources by the child that may include YMCA
or other physical fitness activities, youth sports programs,
karate classes, club memberships, summer camps, arts
activities, etc.
Regular afterschool programs and/or other types of child
care are commonly arranged so that the caregiver(s) can
work and/or attend school. Child care includes day care as
well as care during afterschool hours, evenings and/or
weekends. Afterschool programs may be recreational
and/or educational (e.g., supervised sports, tutoring, help
with homework) but their primary purpose is to provide
supervision of youths so that caregivers may work, attend
school, etc. Do not include respite, recreational activities,
behavioral or therapeutic aide, or caregiver/family support
services that are described in other questions.
Transportation services are transportation to appointments
(e.g., therapy sessions) and other scheduled mental health
services and activities, or reimbursement for public
transportation, van rentals, etc.
Respite care is a planned break for families wherein
trained parents or counselors assume the duties of
caregiving to allow the parent/caregivers a break. The
service may be provided in the child’s home or in other
community locations or in residential settings.
A residential therapeutic camp or wilderness program
involves children/youth and staff living together in a
wilderness or other camp environment often located
outside of the community. Treatment often focuses on
group process, and social skills development.
Inpatient hospitalization is the placement of child/youth in
a hospital for observation, evaluation, and/or treatment.
Services are usually medically oriented and may include
24-hour supervision; services may be used for short-term
treatment and crisis stabilization.

Generic Service Name
30. Residential treatment center

31. Therapeutic group home

32. Therapeutic foster care

33. Flexible funds

34. Informal support

35. School-based services

Site-Specific
Service Name

Definitions and Descriptions
A residential treatment center is a secure residential
facility that typically serves 10 or more children and youth
and provides 24-hour staff supervision, and may include
individual therapy, group therapy, family therapy,
behavior modification, skills development, education, and
recreational services. Lengths of stay tend to be longer in
residential treatment centers than in hospitals.
A therapeutic group home is a 24-hour residential
placement in a home-like setting with a relatively small
group of children with emotional and/or behavior
problems. Therapeutic care employs a variety of treatment
approaches and includes counseling, crisis support,
behavior management, and social and independent living
skills development.
A therapeutic foster home is a 24-hour residential
placement in a home with caregivers who are trained in
behavior management and social and independent living
skills development for children and youth with emotional
and behavioral problems.
Flexible funds are money for non-mental health service
items such as rent, utilities, or temporary living expenses
(e.g., clothes, food, bills, a special item, car repairs, etc.).
Informal support is defined as assistance from persons
who provide support to the child and family without
compensation from any formal service system. This type
of support includes asking a relative or friends to babysit a
child, support received from someone’s church, etc.
School-based services related to child’s emotional and
behavioral problems often include educational assessment
or testing; a self-contained special education classroom; a
resource room; a one-to-one classroom aide; and/or an
Individualized Education Plan (IEP).

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

MULTI-SECTOR SERVICE CONTACTS,
REVISED: Staff as Caregiver—Follow-Up
(MSSC–RS–F)
/

MSRDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

MSRRESP (Respondent for interview)

2 = Staff as Caregiver (staffperson who has acted as the
child’s day-to-day caregiver for the majority of the past 6
months)

MSRINTV (Who administered interview)

2 = Data collector

MSRMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

MSRLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Date last modified: December 2009

Multi-Sector Service Contacts, Revised:
Staff as Caregiver—Follow-Up (MSSC–RS–F)

CHILD ID:

The next set of questions is about specific types of services (child’s name) and/or his/her family may have
received in the past 6 months. Some of the questions are about services that (child’s name) may have
received, while others are about services his/her family may have received related to (child’s name)’s
care, or services that (child’s name) and his/her family may both have received. These services may
include treatment received from a therapist or clinician such as individual therapy, or support such as
respite care, case management, or transportation.
Please keep in mind the various services (child’s name) and his/her family have received from all the
people, organizations, and agencies involved with (child’s name) during the past 6 months. Services may
include those received through (child’s name)’s school, a child welfare agency, the police, or the courts.
All of these services and agencies are part of the service system in your community that works with
children and families.
1.

Within the past 6 months, has (child’s name) or his/her family received any services related to the
emotional or behavioral problems (child’s name) might have had? [NOTE TO INTERVIEWER:
Please show respondent the full list of services and the description of each service.]
1 = No
2 = Yes [GO TO QUESTION #2]
1a.

What was the reason that (child’s name) and/or his/her family did not receive any services?
1 = Completed services/discharged
2 = Decided not to continue services
3 = Did not need services
4 = Was not aware of any services or no services were offered
5 = Was not evaluated
6 = Problems with case managers (e.g., case managers not showing up or contacting
family)
7 = Ineligible for services
8 = Moved out of area and not received any services in the new area
9 = Child placed out of area (hospital, residential center, detention) and not received
any services in the new area
10 = Scheduling challenges
11 = Was evaluated, but waiting for assessment results
12 = Other—please specify __________________________

1b.

What was the last date (child’s name) and his/her family received any services?
__________________________
(mm/dd/yyyy)

[IF QUESTION #1a = 2, GO TO QUESTION #1c. OTHERWISE, END OF QUESTIONNAIRE.]
1c.

Why did (child’s name)’s family decide not to continue services?
_________________________________________________________________________
_________________________________________________________________________

[IF NO SERVICES WERE RECEIVED IN THE PAST 6 MONTHS, END OF QUESTIONNAIRE.]

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
1

Multi-Sector Service Contacts, Revised:
Staff as Caregiver—Follow-Up (MSSC–RS–F)

CHILD ID:

2.

In the past 6 months, did (child’s name) or his/her family receive services under (site’s specific
name for the system of care)?
1 = No [GO TO QUESTION #5]
2 = Yes
2a.

Did (child’s name) and his/her family receive wraparound services? By wraparound, we mean
a process through which providers collaborate with the family to develop an integrated and
creative service plan tailored to the strengths and specific needs of the child and family using
a team that includes the family, teachers, clinicians, friends, and a facilitator to coordinate the
process. Services are “wrapped around” the child and family in their home, school, and
community rather than less accessible or more restrictive places (like the provider’s office or
a residential treatment center).
1 = No
2 = Yes

2b.

Did (child’s name) and his/her family have a youth and family team?
1 = No
2 = Yes

[NOTE TO INTERVIEWER: Questions #3 and #4 are skipped for “staff as caregiver” as they are not
applicable for this respondent.]
5.

In the past 6 months, did (child’s name) or his/her family receive services provided in their
community under any other programs, for example, (site’s specific name[s] for programs other
than the system of care)?
1 = No
2 = Yes

[NOTE TO INTERVIEWER: Clarify that these are services asked about in MSSC–RS.]
6.

In the past 6 months, did (child’s name) or his/her family receive services provided outside their
community under any other programs, for example, (site’s specific name[s] for programs other
than the system of care)?
1 = No
2 = Yes

[CARD 1]
7.

What agencies were involved in providing services to (child’s name) and his/her family? [Select all
that apply]
1 = Mental health
2 = Education
3 = Social services/child welfare
4 = Juvenile justice
5 = Health
6 = Family court
7 = Other—please specify __________________________

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
2

Multi-Sector Service Contacts, Revised:
Staff as Caregiver—Follow-Up (MSSC–RS–F)

CHILD ID:

[CARD 2]
8.

Please tell me if (child’s name) or his/her family received services in any of the following locations
in the past 6 months and whether these locations were convenient. [Select all that apply]
In the past 6
months, did
(child’s name) or
his/her family
receive services in
this location?

Service Location

a.
Was the
location
convenient?

No

Yes

No

Yes

1 = Mental health clinic or private practice

1

2

1

2

2 = School

1

2

1

2

3 = Juvenile court/probation

1

2

1

2

4 = Social services or child welfare offices

1

2

1

2

5 = Community location or service center (i.e.,
Boys’/Girls’ Clubs, YMCA, place of worship)

1

2

1

2

6 = Psychiatric hospital/psychiatric unit

1

2

1

2

7 = Medical hospital

1

2

1

2

8 = Home

1

2

1

2

9 = Non-hospital residential setting

1

2

1

2

10 = Jail/youth detention

1

2

1

2

1

2

1

2

11 = Other—please specify
________________________________________

[IF YES]

Now I’m going to ask you some questions about the specific services that (child’s name) or his/her family
received in the past 6 months. First, I’ll briefly describe a type of service to you, then I’ll ask whether or
not (child’s name) or his/her family received the service. If they received the service, I will ask you how
often the service was received. Please try to estimate, to the best of your ability, the number of days they
received that service over the entire 6-month period. Remember that all of your answers will be kept
confidential.
Before we begin this set of questions, let’s review the 6-month timeline that we’ll be using. It is similar to
the one we have used with the other questionnaires.

[TIMELINE]
Since some of the following questions only apply to children who have had a problem with substance
abuse, I need to ask you about this again.
For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
3

Multi-Sector Service Contacts, Revised:
Staff as Caregiver—Follow-Up (MSSC–RS–F)

CHILD ID:

9.

In the past 6 months, has (child’s name) had a problem with substance abuse, including alcohol and
drugs?
1 = No [For Questions #10–35, do not ask questions in column “c”]
2 = Yes [For Questions #10–35, ask questions in all columns]

[NOTE TO INTERVIEWER: For each of the following questions (#10–35), read the brief description of
the service and site-specific names of the service. Then ask the respondent if this service was received in
the past 6 months. If it was received, continue with additional follow-up questions about this service. If
the service was not received, circle No and continue with the next service description. Only ask “c” if
respondent answered “yes” to Question #9 (i.e., child had a problem with alcohol and drugs in the past 6
months), otherwise proceed to “d.”]

[CARD 3] [Service Definitions and Descriptions List]
b.
How well did the service
meet the needs of (child’s
name) and/or his/her
family?

1 = No
2 = Yes

_____

1 = No
2 = Yes

[IF
YES]

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

13. Medication treatment
monitoring

1 = No
2 = Yes

_____

14. Group therapy

1 = No
2 = Yes

_____

12. Family preservation

15. Individual therapy
16. Case management

For all variables and data elements:
Date last modified: December 2009

1 = No
2 = Yes
1 = No
2 = Yes

[IF
YES]

_____
_____

666 = Not Applicable
777 = Refused

Extremely well

11b. Family advocacy and peer
support provided by
trained advocate

_____

Very well

11a. Mobile crisis outreach

1 = No
2 = Yes

Moderately well

11. Crisis stabilization

a.
On how
many
days?

Somewhat well

10. Assessment or evaluation

[IF
YES]

d.
Did (child’s
name)’s
family pay
at least part
of the costs
of this
service?

Not at all well

Service

In the past 6
months, did
(child’s name)
and/or his/her
family receive
this service?

c.
Was this
service related
to (child’s
name)’s
alcohol or
substance
abuse
problem?

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

888 = Don’t Know
999 = Missing
4

Multi-Sector Service Contacts, Revised:
Staff as Caregiver—Follow-Up (MSSC–RS–F)

CHILD ID:

b.
How well did the service
meet the needs of (child’s
name) and/or his/her
family?

21. Youth transition
22. Caregiver or family support
23. Vocational training
24. Recreational activities

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

1 = No
2 = Yes

[IF
YES]

_____

1 = No
2 = Yes

_____

25. Afterschool programs or child
care

1 = No
2 = Yes

_____

26. Transportation

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

28. Residential therapeutic camp or
wilderness program

1 = No
2 = Yes

_____

29. Inpatient hospitalization

1 = No
2 = Yes

_____

1 = No
2 = Yes

_____

27. Respite care

30. Residential treatment center
31. Therapeutic group home
32. Therapeutic foster care

For all variables and data elements:
Date last modified: December 2009

1 = No
2 = Yes
1 = No
2 = Yes

[IF
YES]

_____
_____

666 = Not Applicable
777 = Refused

Extremely well

20. Independent living

_____

Very well

19. Behavioral/therapeutic aide

1 = No
2 = Yes

Moderately well

18. Day treatment

a.
On how
many
days?

Somewhat well

17. Family therapy

[IF
YES]

d.
Did (child’s
name)’s
family pay
at least part
of the costs
of this
service?

Not at all well

Service

In the past 6
months, did
(child’s name)
and/or his/her
family receive
this service?

c.
Was this
service related
to (child’s
name)’s
alcohol or
substance
abuse
problem?

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

1 = No
2 = Yes

888 = Don’t Know
999 = Missing
5

Multi-Sector Service Contacts, Revised:
Staff as Caregiver—Follow-Up (MSSC–RS–F)

CHILD ID:

b.
How well did the service
meet the needs of (child’s
name) and/or his/her
family?

Not at all well

Somewhat well

Moderately well

Very well

Extremely well

c.
Was this
service related
to (child’s
name)’s
alcohol or
substance
abuse
problem?

33. Flexible funds

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

34. Informal support

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

35. School-based services

1 = No
2 = Yes

1

2

3

4

5

1 = No
2 = Yes

In the past 6
months, did
(child’s name)
and/or his/her
family receive
this service?

Service

[IF
YES]
a.
On how
many
days?

d.
Did (child’s
name)’s
family pay
at least part
of the costs
of this
service?

1 = No
2 = Yes

16e. [IF YES to Case management] How many case managers did (child’s name) and his/her
family have in the past 6 months?
_____

[CARD 4]
33e. [IF YES to Flexible funds] What were the flexible funds used for? [Select all that apply]
1 = Housing
2 = Activities
3 = Utilities
4 = Supplies/groceries
5 = Clothing
6 = Furnishings/appliances
7 = Automobiles
8 = Transportation (contracted)
9 = Transportation (reimbursed)
10 = Incentive
11 = Medical
12 = Legal
13 = Other—please specify ____________________________________________

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
6

Multi-Sector Service Contacts, Revised:
Staff as Caregiver—Follow-Up (MSSC–RS–F)

CHILD ID:

34e. [IF YES to Informal support] What types of informal support did (child’s name)’s family
receive? [Select all that apply]
1 = Emotional support (e.g., someone to listen to you, someone who knows what you
are going through)
2 = Physical support with caregiving tasks (e.g., babysitting, etc.)
3 = Financial support
4 = Transportation
5 = Informational support
6 = Other—please specify ____________________________________________
[NOTE TO INTERVIEWER: Questions #36–47 are skipped for “staff as caregiver,” as they are not
applicable for this respondent.]

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
7

Service Definitions and Descriptions
(To be used with the MSSC–RS questionnaire)

Generic Service Name
10. Assessment or evaluation

11. Crisis stabilization

11a. Mobile crisis outreach

11b. Family advocacy and peer
support provided by
trained advocate

12. Family preservation

Site-Specific
Service Name

Definitions and Descriptions
Assessment and evaluation services are used to determine
a child’s psychological, social, and behavioral strengths
and challenges. These are typically performed by a
psychologist or psychiatrist. Types of assessment may
include neurological, psychosocial, educational, and
vocational.
Crisis stabilization services are designed to stabilize a
child experiencing acute emotional or behavioral
difficulties. These services may include the development
of crisis plans, 24-hour telephone support, mobile
outreach, intensive in-home support during crisis, and
short-term emergency residential services.
Mobile crisis outreach services are provided by team
members (usually trained professionals holding either a
master’s level or bachelor’s level degree in the social
services field) who undergo intensive training in
counseling and crisis intervention skills and their
application. Teams respond rapidly to emergency requests
for services (usually within one hour of receiving a
request) wherever they are needed (like a person’s home,
schools, businesses or hospitals). Upon arrival, team
members will assess the situation, attempt to stabilize and
diffuse the crisis, provide counseling as needed, and
provide referrals to other resources. Typically, within 24
hours a team member will make a follow-up call with the
child and family to check on the child’s well-being.
Family advocacy services include speaking, acting or
writing with minimal conflict of interest on behalf of the
interests of child and family, in order to promote, protect
and defend the welfare of and justice for the child and
family by being on their side and no-one else’s, being
primarily concerned with their fundamental needs, and
remaining loyal and accountable to them in a way which is
empathic and vigorous. Peer support services include
caregivers who have coped with children with a variety of
problems (e.g., mental health and chronic illness) sharing
their experiences and offering support in various forms to
and caregivers who are coping with similar problems.
Those providing these services should be trained in their
roles as advocates and peer supports.
Family preservation services are designed to keep the
family together during difficult or stressful times. These
services may include 24-hour access to support services,
intensive in-home support during crisis when a child is at
risk of out-of-home placement or when the child is
returning from out-of-home placement. These are distinct
from crisis stabilization services as they may continue for
several months during transition or crisis.

Generic Service Name
13. Medication treatment
monitoring

14. Group therapy

15. Individual therapy

16. Case management

17. Family therapy

18. Day treatment

19. Behavioral/therapeutic aide

20. Independent living

21. Youth transition

Site-Specific
Service Name

Definitions and Descriptions
Medication treatment and monitoring services typically
include the prescription of psychoactive medications by a
physician (e.g., psychiatrist) that are designed to alleviate
symptoms and promote psychological growth. Treatment
includes periodic assessment and monitoring of the child’s
reaction(s) to the drug.
Group therapy relies on interaction among a group of
individuals, which could include children or children and
adults. Groups are typically facilitated by a therapist to
promote psychological and behavior change. Groups
typically meet together on a regular basis.
Individual therapy relies on interaction between
therapist/clinician and child to promote psychological and
behavior change.
Case management or service coordination involves finding
and organizing multiple treatment and support services,
and may also include preparing, monitoring, and revising
service plans; and advocating on behalf of the child and
family. Case managers may also provide supportive
counseling.
Family therapy involves a variety of family members such
as caregivers and/or siblings with or without the child
present. Interaction among family members is typically
facilitated by a therapist or counselor.
Day treatment consists of intensive, nonresidential
services that include an array of counseling, education,
and/or vocational training. These services involve a child
or youth for at least 5 hours a day, for at least 3 days a
week, and are offered in a variety of settings, including
schools, mental health centers, hospitals, or other
community locations.
Behavioral or therapeutic aide services are the supervision
of a child by trained adults in the home, the school, or
other community locations. The aide might provide
support and may assist with tutoring or recreational
activities.
Independent living services are designed to prepare older
adolescents to live independently and reduce their reliance
on the family or service system. These services may
include social and community living skills development
and peer support (e.g., look for job, pay bills, job skill
training, etc.).
Transition services are designed to help older adolescents
to move from the child system to the adult mental health
system.

Generic Service Name
22. Caregiver or family support

23. Vocational training

24. Recreational activities

25. Afterschool programs or child
care

26. Transportation

27. Respite care

28. Residential therapeutic camp or
wilderness program

29. Inpatient hospitalization

Site-Specific
Service Name

Definitions and Descriptions
Caregiver or family support services are provided to
caregivers or siblings (e.g., family activities, behavior
management training, parent classes, support groups,
individual therapy for caregiver or other family members).
Do not include recreational activities,
behavioral/therapeutic aide, transportation services, respite
care, afterschool activities or child care, which are
described in other questions.
Vocational training refers to the development life skills
and job skills designed to assist young adults with the
transition to independent living. (Parenting classes,
managing money, holding a job etc.)
Recreational activities are the use of community
recreation resources by the child that may include YMCA
or other physical fitness activities, youth sports programs,
karate classes, club memberships, summer camps, arts
activities, etc.
Regular afterschool programs and/or other types of child
care are commonly arranged so that the caregiver(s) can
work and/or attend school. Child care includes day care as
well as care during afterschool hours, evenings and/or
weekends. Afterschool programs may be recreational
and/or educational (e.g., supervised sports, tutoring, help
with homework) but their primary purpose is to provide
supervision of youths so that caregivers may work, attend
school, etc. Do not include respite, recreational activities,
behavioral or therapeutic aide, or caregiver/family support
services that are described in other questions.
Transportation services are transportation to appointments
(e.g., therapy sessions) and other scheduled mental health
services and activities, or reimbursement for public
transportation, van rentals, etc.
Respite care is a planned break for families wherein
trained parents or counselors assume the duties of
caregiving to allow the parent/caregivers a break. The
service may be provided in the child’s home or in other
community locations or in residential settings.
A residential therapeutic camp or wilderness program
involves children/youth and staff living together in a
wilderness or other camp environment often located
outside of the community. Treatment often focuses on
group process, and social skills development.
Inpatient hospitalization is the placement of child/youth in
a hospital for observation, evaluation, and/or treatment.
Services are usually medically oriented and may include
24-hour supervision; services may be used for short-term
treatment and crisis stabilization.

Generic Service Name
30. Residential treatment center

31. Therapeutic group home

32. Therapeutic foster care

33. Flexible funds

34. Informal support

35. School-based services

Site-Specific
Service Name

Definitions and Descriptions
A residential treatment center is a secure residential
facility that typically serves 10 or more children and youth
and provides 24-hour staff supervision, and may include
individual therapy, group therapy, family therapy,
behavior modification, skills development, education, and
recreational services. Lengths of stay tend to be longer in
residential treatment centers than in hospitals.
A therapeutic group home is a 24-hour residential
placement in a home-like setting with a relatively small
group of children with emotional and/or behavior
problems. Therapeutic care employs a variety of treatment
approaches and includes counseling, crisis support,
behavior management, and social and independent living
skills development.
A therapeutic foster home is a 24-hour residential
placement in a home with caregivers who are trained in
behavior management and social and independent living
skills development for children and youth with emotional
and behavioral problems.
Flexible funds are money for non-mental health service
items such as rent, utilities, or temporary living expenses
(e.g., clothes, food, bills, a special item, car repairs, etc.).
Informal support is defined as assistance from persons
who provide support to the child and family without
compensation from any formal service system. This type
of support includes asking a relative or friends to babysit a
child, support received from someone’s church, etc.
School-based services related to child’s emotional and
behavioral problems often include educational assessment
or testing; a self-contained special education classroom; a
resource room; a one-to-one classroom aide; and/or an
Individualized Education Plan (IEP).

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 8 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

CULTURAL COMPETENCE AND SERVICE
PROVISION QUESTIONNAIRE, REVISED
(CCSP–R)
/

CCSPDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

CCSPRESP (Respondent for interview)

1 = Caregiver (child’s caregiver in a family, household
environment)
3 = Youth without caregiver (independent youth)

CCSPINTV (Who administered interview)

2 = Data collector

CCSPMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

CCSPLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Date last modified: September 2012

Cultural Competence and Service
Provision Questionnaire, Revised (CCSP–R)

CHILD ID:

Some people feel that their cultural heritage, that is, their beliefs, traditions, values, and practices, is
important to consider when working with people who provide services to their children. Others do not.
This cultural heritage may be related to your race, ethnicity, religious affiliation, sexual orientation,
income level, or geographic location.
I’m going to ask you a few questions about things that may or may not be important to you that have to
do with cultural heritage, or “culture” for short. Please let me know if these things are not at all
important, somewhat important, moderately important, very important, or extremely important.

[CARD 1]
Not at all Somewhat Moderately Very Extremely
important important important important important
1.

2.

3.

4.

How important is it that you and your
child have a service provider who
understands the customs, practices, and
traditions of (child’s name)’s cultural
heritage?

1

2

3

4

5

How important is it that the beliefs,
traditions, and practices of (child’s
name)’s cultural heritage be included in
service planning and provision?

1

2

3

4

5

How important is it that the person you
and your child have seen most often about
the emotional or behavioral problems
(child’s name) has been having is of the
same cultural heritage as (child’s name)?

1

2

3

4

5

In the past 6 months, has (child’s name) or your family received any services related to the
emotional or behavioral problems (child’s name) might have had?
1 = No [END OF QUESTIONNAIRE]
2 = Yes

Now, I’d like you to think about the person you and your child have seen most often about the emotional
or behavioral problems (child’s name) has been having since [6-month date]. This person may be a care
coordinator, case manager, therapist, or someone else.
5.

Is this person of the same racial or ethnic group or culture as (child’s name)?
1 = No
2 = Yes

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
1

Cultural Competence and Service
Provision Questionnaire, Revised (CCSP–R)

CHILD ID:

[NOTE TO INTERVIEWER: Remind the respondent to keep the same provider in mind for the next set of
questions.]
Thinking about the provider that you and your child have seen most often in the past 6 months, please
respond by indicating never, not very often, sometimes, most of the time, or always to the items that
describe how often the statements are true for you and your child.

[CARD 2]
Never

Most
Not very
of the
often Sometimes time

Always

6.

My child’s provider understands my family’s
beliefs about mental health.

1

2

3

4

5

7.

My child’s provider speaks the same
language(s) that I or (child’s name) speaks.

1

2

3

4

5

8.

I feel comfortable discussing with my child’s
provider alternative therapies (e.g., herbal
medicines or traditional healers) or other ways
to work with (child’s name).

1

2

3

4

5

My child’s provider asks about my family’s
traditions, beliefs, and values when planning or
providing services.

1

2

3

4

5

10.

I feel like other children have access to better
services than (child’s name).

1

2

3

4

5

11.

Materials given to me (such as brochures or
newsletters) about the program or available
services are easy to understand.

1

2

3

4

5

12.

My child’s provider attends to my and (child’s
name)’s cultural needs.

1

2

3

4

5

13.

My child’s provider is comfortable interacting
with me and (child’s name).

1

2

3

4

5

9.

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
2

OMB No. 0930-0307
Expiration Date: xx/xx/xxxx
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0930-0307. Public reporting burden for this
collection of information is estimated to average 7 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

YOUTH SERVICES SURVEY FOR FAMILIES
Abbreviated Version (YSS–F)
/

YSSFDATE (Today’s date)
Month

/
Day

Year

CHILDID (National evaluation ID)
TIMEFRAM (Assessment period)

2 = 6 months
3 = 12 months
4 = 18 months
5 = 24 months

YSSFRESP (Respondent for interview)

1 = Caregiver (child’s caregiver in a family, household
environment)

YSSFINTV (Who administered interview)

2 = Data collector

YSSFMETH (Method of administering interview)

1 = In person, hard copy
2 = Telephone, hard copy
3 = In person, computer assisted
4 = Telephone, computer assisted

YSSFLANG (Language version of interview)

1 = English
2 = Spanish
3 = Other

Date last modified: September 2012

CHILD ID:

Youth Services Survey for Families, Abbreviated Version (YSS–F)

Please think about all the services (child’s name) and your family may have received over the past 6
months. These services may include treatment received from a therapist or clinician such as individual
therapy, or support such as case management, or transportation. These services may also include help
(child’s name) and your family may have received through your school, a child welfare agency, the
police, and the courts. All of these services are part of the service system in your community that works
with children and families.
Has (child’s name) or your family received any services like these in the past 6 months?
1 = No [END OF QUESTIONNAIRE]
2 = Yes
We are interested in knowing what you think about the services your child and family have received
during the past 6 months.
Your opinions are important, so please be honest and tell us what you think. We want to know how you
felt, good or bad! Remember that what you say will be kept confidential. People who provide services to
(child’s name) and your family will never find out what you have told us.
I will read you several statements. For each of the statements, please tell me the extent to which you
disagree or agree that the statement describes your experience.

[CARD]
Strongly
Strongly
disagree Disagree Undecided Agree
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.

1

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.

1

2

3

4

5

7.

The services my child and/or family received
were right for us.

1

2

3

4

5

8.

The location of services was convenient for us.

1

2

3

4

5

9.

Services were available at times that were
convenient for us.

1

2

3

4

5

10.

My family got the help we wanted for my child.

1

2

3

4

5

11.

My family got as much help as we needed for
my child.

1

2

3

4

5

12.

Staff treated me with respect.

1

2

3

4

5

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
1

CHILD ID:

Youth Services Survey for Families, Abbreviated Version (YSS–F)

Strongly
Strongly
disagree Disagree Undecided Agree
agree
13.

Staff respected my family’s religious and
spiritual beliefs.

1

2

3

4

5

14.

Staff spoke with me in a way that I understood.

1

2

3

4

5

15.

Staff were sensitive to my cultural and ethnic
background.

1

2

3

4

5

As a result of the services my child and/or family received:
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 better 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 the things he/she
wants to do.

1

2

3

4

5

As a result of the services my child and/or family received: please answer for relationships with persons
other than your mental health or other provider(s)
23.

I know people who will listen and understand
me when I need to talk.

1

2

3

4

5

24.

I have people whom I am comfortable talking
with about my child’s problems.

1

2

3

4

5

25.

In a crisis, I would have the support I need from
family and friends.

1

2

3

4

5

26.

I have people with whom I can do enjoyable
things.

1

2

3

4

5

27.

What has been the most helpful thing about the services your child received over the past 6 months?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

*Developed by Brunk et al. (1999)

For all variables and data elements:
Date last modified: December 2009

666 = Not Applicable
777 = Refused

888 = Don’t Know
999 = Missing
2