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Children's Mental Health Provider's Survey

Please participate in the Alabama Family Ties survey of providers.  We will use the collected 
information to make referrals for families seeking mental health services in Alabama.  Our 
organization seeks to establish support groups in communities across the state and 
advocate for additional mental health services for children and adolescents.

Survey Contents

  1. Date
  2. Contact information
  3. Insurance
  4. Provider category
  5. Children's services provided by:
  6. Adolescent services provided by:
  7. Types of services offered to children
  8. Types of services offered to adolescents
  9. Gender specific services for adolescents
  10. Request for Alabama Family Ties information
  11. Interest in attending a statewide workshop for children and adolescents
  12. Topics or speakers that should be included in a statewide conference
  13. Children or adolescent mental health services needed in your community

  1. Enter the date  

  2. Please provide the following contact information:

    First Name
    Last Name
    Middle Initial
    Title
    Organization
    Street Address
    Address (cont.)
    City
    State/Province
    Zip/Postal Code
    Country
    Work Phone
    FAX
    E-mail
    URL

  3. I accept insurance:

  4. Please list me in the Alabama Family Ties resource directory as:

    Independent Practitioner        Advocacy/Family Support Agency 
Service Provider State Agency   Other

  5. Children's services are provided by:

    Licensed Psychologist             Licensed Professional Counselor
Pediatric Neurologist             Licensed Certified Social Worker
Psychiatrist                      Other

  6. Adolescent services are provided by:

    Licensed Psychologist             Licensed Professional Counselor 
Pediatric Neurologist             Licensed Certified Social Worker
Psychiatrist                      Other

  7. Children's services include:

    Outpatient                 Residential                
Information/Referral       Parent Support Groups    
Educational Materials      Advocacy                   
Inservice Training         Counseling               
Day Treatment              Inpatient                  
Children's Support Groups  Speakers Bureau          
Toll Free Phone Line       Other

  8. Adolescent services include:

    Outpatient                 Residential                
Information/Referral       Parent Support Groups    
Educational Materials      Advocacy                   
Inservice Training         Counseling               
Day Treatment              Inpatient                  
Children's Support Groups  Speakers Bureau          
Toll Free Phone Line       Other

  9. Adolescent services are provided for:

    Males
    Females
    Both

  10. I would like to have Alabama Family Ties brochures and newsletters for my waiting room:

    Yes
    No

  11. I would be interested in attending a statewide workshop addressing 
    the mental health needs of children and adolescents:

    Yes
    No

  12. What topics or speakers should be included in a statewide meeting?


  13. Please list the unmet mental health service needs of 
    children and adolescents in your community.



 

 
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