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New SBHC/Wellness Center Information Survey
The California School-Based Health Alliance (CSHA) has a database of all the school-based health centers (SBHCs) in California so that we share training opportunities and provide technical assistance and support. Please fill out the following survey so that we may include new SBHCs in our state database. If you have any questions or concerns, please email our Program Assistant at
info@schoolhealthcenters.org
.
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School-Based Health Center or Wellness Center Name
Your answer
School-Based Health Center or Wellness Center Address
Your answer
School-Based Health Center or Wellness Center Phone Number
Your answer
Please list the all the schools the school-based health center or wellness center serves.
Your answer
Services provided
Medical
Mental Health
Reproductive Health, Screening/Prevention
Reproductive Health Comprehensive
Community Health Education
Educational Support
Dental Prevention
Dental Treatment
Nutrition/Fitness
Telemedicine
Youth Engagement
Vision
Please list the youth programs you have.
Your answer
Main Contact Name
Your answer
Main Contact Title
Your answer
Main Contact Phone Number
Your answer
Main Contact Email Address
Your answer
Secondary Contact Name
Your answer
Secondary Contact Title
Your answer
Secondary Contact Phone Number
Your answer
Secondary Contact Email Address
Your answer
If there are additional people who want to be included in our email list, please put their name, role and email address below:
Your answer
Where does the school-based health center or wellness center provide services?
On-school site
Off school site
Mobile van
Telehealth only
Clear selection
If you are on-site, do you serve an elementary, middle or high school? (select all that apply)
Elementary School
Middle School
High School
Who does your school-based health center or wellness center serve? (select all that apply)
Students enrolled in the SBHC's or wellness center's school
Students from other schools
Out-of-school youth
Faculty/school personnel
Family members
Community members
What is the LEAD organization for your school-based health center or wellness center?
Your answer
What organization is the medical provider?
Your answer
What organization is the behavioral health provider?
Your answer
Are there any organizations providing other services? If so, please specify:
Your answer
Does your organization have any other school-based health centers or wellness centers? (If so, please fill out another form to indicate the information for any other SBHCs or Wellness Centers.) Please note that mobile vans visiting multiple schools is not considered multiple SBHCs.
Yes
No
Clear selection
What is your school-based health center or wellness center doing well? Any innovative best practices we should be highlighting?
Your answer
What might you need additional support from CSHA? (e.g operations, billing, substance use, dental)?
Your answer
If CSHA focused on one thing next year, what do you think it should be?
Your answer
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