School-Based Health Centers - Implementation Tools
Health needs survey for parents/guardians
(Community School District #15, Brooklyn, NY)

In an effort to better involve parents/guardians in the delivery of health care services to their children, we would like to ask you a few questions regarding the health needs of your child.

Please take a few moments to answer the following questions. You do not need to put your name or your child's name on this form.

1) Has your child/teen been to a doctor or nurse in the past year?

2) Are there barriers that make it difficult for you to take your child/teen to the doctor or nurse? (Check all that apply)

3) When would you like your child/teen to be seen by a health care professional? (Check all that apply)

4) In your opinion, what are some childhood/adolescent health problems/issues that concern you? (Check all that apply)

5) Does your child/teen get depressed or stressed out?

6) How do you view your or your child's doctor or nurse? (Check all that apply)

7) Did you know there was a School Based Health Center in your child's school that provides comprehensive health care at no cost to you?

8) Are you familiar with the services at the School Based Health Center?

9) If your child/teen has not used the School Based Health Center, what are your reasons? (Check all that apply)

11) If you have used the School Based Health Center at any time, have you been satisfied with the services your child/teen has received?