Youth Service Center Parent Survey 2017-2018
Youth Service Centers serve children in middle and high school and offer a unique blend of programs and services to serve the special needs of their students and family populations. The goal is to meet the needs of all children and their families served by the centers as a means to help them do well in school. To help us plan for the upcoming year please fill out this survey and return to school.
Name of student/s enrolled
Your answer
My child/children attend - Choose School below *
Required
BASIC FAMILY NEEDS
In the past 12 months have you had difficulty providing adequate food for your family? *
In the past 12 months have you had difficulty finding adequate housing for your family? *
In the past 12 months have you needed assistance with paying your rent or mortgage? *
In the past 12 months have you had difficulty supplying your child with necessary school supplies? *
Are you raising children other than your own? *
HEALTH SERVICES
In the past 12 months have you or your child needed assistance with medical care? *
In the past 12 months have you or your child needed assistance with dental care? *
In the past 12 months have you or your child needed assistance with vision care? *
In the past 12 months have you or your child needed assistance with hearing care? *
Does your child have a primary care provider? *
Do you and/or your child have any type of vision or hearing insurance? *
Would you like information about a substance abuse treatment program for teens? *
Have you filled out the Household Income Form and returned it to school? (This information is very important to help with funding for our youth service centers.) *
MENTAL HEALTH SERVICES
Would you like information on issues such as gangs, drug or alcohol abuse or prevention, self esteem, teen pregnancy or prevention, self harm (like cutting)? *
If you answered yes to the question above please explain below.
Your answer
Do you have a teen mom currently living in your home? *
Do you need information on support groups for teen moms and dads? *
EDUCATIONAL SUPPORT
Do you need information on obtaining your GED? *
Would you like information about a support group for grandparents or people raising children other than their own? *
Tell us what you would like to learn about.
Your answer
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