MDCH - Annual Family Survey

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Annual Family Survey

FAMILY SUPPORT SUBSIDY PROGRAM

Please complete this survey ONLY if your child is enrolled in this program

First, we need to know about your child.

1. What is the child's birth date?

2. What is the child's gender?

	Male
	Female

3. What race best describes your child?

You may choose more than one.

	White
	American Indian or Alaska Native
	Native Hawaiian or Other Pacific Islander
	Black or African American
	Asian
	Other race
	Unknown Race

4. Please mark your child's ethnicity.

	Hispanic or Latino
	Not Hispanic or Latino

5. What is your child's educational eligibility category?

Check only one

	Cognitive Impairment
	Severe Multiple Impairments
	Autism Spectrum Disorder

6. Did your child return to your home from an out-of-home placement during the last year?

Check One

	Yes - Please answer question 7
	No - Please skip question 7

7. If your child DID return home during the last year, how much did the subsidy influence your decision to bring the child home?

Check One

	Not at all
	A little
	Some
	Greatly
	Very Greatly

8. Please check all the items or services you purchased with the subsidy in the last year?

	Adaptive equipment for your child	Behavioral aides
	Camp or recreation for your child	Changes to make your house more accessible
	Clothing for your child	Day care for your child with disabilities
	Diapers/Pull-ups	Educational aides or toys
	General household expenses	Individual or family counseling
	In-home nursing care	Medical expenses
	Occupational, physical or speech therapy	Respite services
	Special foods	Transportation expenses

9. If you used the subsidy to purchase items not listed in question 8, please list them here.

10. When did your family receive a subsidy check FOR THE FIRST TIME?

Check One

	1-12 months ago
	13-24 months ago
	More than 24 months ago

11. How often is the monthly amount of the subsidy adequate to help you meet your child's needs?

Check One

	Never
	Seldom
	Sometimes
	Usually
	Always

12. How satisfied or dissatisfied are you with the amount of the subsidy?

	Very Dissatisfied
	Somewhat Dissatisfied
	Neutral
	Somewhat Satisfied
	Very Satisfied

13. How satisfied or dissatisfied are you with how your application was handled at the community mental health services agency?

	Very Dissatisfied
	Somewhat Dissatisfied
	Neutral
	Somewhat Satisfied
	Very Satisfied

14. How satisfied or dissatisfied are you with the information you received about the program?

	Very Dissatisfied
	Somewhat Dissatisfied
	Neutral
	Somewhat Satisfied
	Very Satisfied

15. How satisfied or dissatisfied are you with your overall experience with the subsidy program?

	Very Dissatisfied
	Somewhat Dissatisfied
	Neutral
	Somewhat Satisfied
	Very Satisfied

16. How much has the subsidy helped meet the special needs of your family?

	Not At All
	A Little
	Some
	Greatly
	Very Greatly

17. How much has the subsidy helped meet the special needs of your child?

	Not At All
	A Little
	Some
	Greatly
	Very Greatly

18. How much has the subsidy improved your family's life?

	Not At All
	A Little
	Some
	Greatly
	Very Greatly

19. How much has the subsidy improved your ability to care for your child?

	Not At All
	A Little
	Some
	Greatly
	Very Greatly

20. How much has the subsidy helped your family do more things together?

	Not At All
	A Little
	Some
	Greatly
	Very Greatly

21. How much has the subsidy eased your financial worries?

	Not At All
	A Little
	Some
	Greatly
	Very Greatly

22. How much has the subsidy reduced the stress in your family's life?

	Not At All
	A Little
	Some
	Greatly
	Very Greatly

23. Please check the items representing services or assistance your family has received from Community Mental Health in the last 12 months.

	Adaptive equipment	Changes to make your house accessible
	Day care	In-home behavioral aides
	Occupational, physical or speech therapy	Person-center planning/family-centered practice
	Services coordination	Specialized medical services
	Training on managing behavior problems	Camp or recreational activities
	Children's Waiver Program	Individual or family counseling
	In-home nursing	Parent support groups
	Respite services	Sibling support groups
	Training on how to teach your child basic skills	Transition to adulthood planning

How often would these services and supports help your family?

25. Adaptive equipment?

Never

Seldom

Sometimes

Often

Almost Always

26. Camp or recreational activities?

Never

Seldom

Sometimes

Often

Almost Always

27. Changes to make your house accessible?

Never

Seldom

Sometimes

Often

Almost Always

28. Children's Waiver Program?

Never

Seldom

Sometimes

Often

Almost Always

29. Day Care?

Never

Seldom

Sometimes

Often

Almost Always

30. Individual or family counseling?

Never

Seldom

Sometimes

Often

Almost Always

31. In-home behavioral aides?

Never

Seldom

Sometimes

Often

Almost Always

32. In-home nursing?

Never

Seldom

Sometimes

Often

Almost Always

33. Occupational, physical or speech therapy?

Never

Seldom

Sometimes

Often

Almost Always

34. Parent support groups?

Never

Seldom

Sometimes

Often

Almost Always

35. Person-centered planning/family-centered practice?

Never

Seldom

Sometimes

Often

Almost Always

36. Respite services?

Never

Seldom

Sometimes

Often

Almost Always

37. Services coordination?

Never

Seldom

Sometimes

Often

Almost Always

38. Sibling support groups?

Never

Seldom

Sometimes

Often

Almost Always

39. Specialized medical services?

Never

Seldom

Sometimes

Often

Almost Always

40. Trainining on how to teach your child basic skills?

Never

Seldom

Sometimes

Often

Almost Always

41. Training on managing behavioral problems?

Never

Seldom

Sometimes

Often

Almost Always

42. Transition to adulthood planning?

Never

Seldom

Sometimes

Often

Almost Always

43. What was your family's taxable income last year?

Please check one.

	Less than $20,000
	$20,000 to $44,999
	$45,000 to $60,000
	More than $60,000

44. In what county does your family live?

24. Please share any comments, concerns or questions.

If you would like someone to contact you, please complete the following:

45. Name:

46. Telephone number, including area code:

47. Street address:

48. City, state and ZIP code:

49. E-mail address:

* Spam Block: (What's this?) Add one plus four and type the answer here:


	Related Content
•	Annual Report, FY 10
•	Annual Report, FY 09
•	Family Support Subsidy Program Brochure
•	Family Support Subsidy Program