Chinese American Community Parent Support Needs Survey 华裔社区家长支持需求调查

UCA Mental Health Community Needs Survey 华裔社区健康支持需求家长调查表

UCA W.A.V.E.S Program 2021
Confidentiality Statement 保密声明

Information collected in this survey will be held in strict confidentiality and will be used in aggregate form only, without individual identifications.

本调查收集的信息将严格保密，并且仅以汇总形式使用，不显示个人识别信息。
Demographic Information 个人基础信息
Name 姓名 (this is optional 大家可以选择匿名）

First Name 名Last Name 姓
Email 邮箱地址*
example@example.com
State 所在州*
Address 地址

Street Address 地址

Street Address Line 2

City 城市State / Province 州/省

Postal / Zip Code 邮政编码
What is your gender? 您的性别*

Female 女性Male 男性Non-binary 非二元性别Prefer not to answer 保密
What is your parental role? 您所担任的家庭角色*

Mother 母亲Father 父亲Grandparent 祖父母Other 其他
For "Other", please specify 若选“其他”，请具体说明:
What is your marital status? 您的婚姻状况*

Single 单身Married 已婚Divorced 离异Widowed 丧偶Prefer not to answer 保密
What is the highest level of education you have completed? 您的最高学历*

Less than high school 高中以下High school 高中Some college / University 部分大学教育College diploma / Certificate 大专文凭/证书Undergraduate degree 本科学士学位Masters / Graduate degree研究生/硕士文凭Doctorate 博士学位Prefer not to answer 保密Other
For "Other", please specify 若选“其他”，请具体说明:
English Skills 英语水平*

Basic 初级Intermediate 中级Advanced 高级
Number of years living in the United States 在美国居住时间*

1 - 5 years 1-5年6-10 years 6-10年11 - 20 years 11-20年21 - 30 years 21-30年>30 years 30年以上
Age of children (choose all that apply) 子女年龄（可多选）*

0 - 5 years 0-5岁6 - 11 years 6-11岁12 - 14 years 12-14岁15 - 18 years 15-18岁>18 years 18岁以上
Needs for Mental Health Support 心理健康支持需求调查
If you have children who have been or are showing signs of mental health issues, how old are they? Check all that apply. 如果您的孩子已被确诊或有心理问题的迹象，他/她目前的年龄？（可多选项）*

0 - 5 years 0-5岁6 - 11 years 6-11岁12 - 14 years 12-14岁15 - 18 years 15-18岁>18 years 18岁以上
If so, please share, to whatever extent you feel comfortable, the nature of your children's mental health challenges (whether clinically diagnosed or not) 若孩子有心理问题，请在您感觉舒适的范围内告知影响孩子心理健康的因素（无论是否被医学确诊）：

Stress 压力Anxiety 焦虑Depression 抑郁Obsessive-compulsive disorder 强迫症Eating disorder 饮食失调Bipolar disorder 躁郁症Schizophrenia or other psychotic disorder 精神分裂或其他精神类疾病Other 其他
For "Other", please specify 若选“其他”，请具体说明：
Have you ever sought help from others? 曾向他人寻求过帮助吗？*

Yes 是的No 不是
If yes, from whom have you sought support? (Please select all that apply.) 若回答“是的”，请问从何种渠道寻求过帮助？（可多选项）*

Primary care physician 初级保健医生Psychologist/Other mental health professional 心理医生/其他精神健康专家School Teachers 学校老师Pastor/Religious figure 牧师/神职人员Other Professionals 其他专业人士Relatives 亲属Friends 朋友Books 书籍Online resources 线上资源Other
Which sources of support are important but need to be better prepared to address mental health issues? 您认为哪些支持来源很重要，但需要做更多准备和进一步完善去解决心理健康问题？

Primary care physician 初级保健医生Psychologist/Other mental health professional 心理医生/其他精神健康专家School Teachers 学校老师Pastor/Religious figure 目是/神职人员Other Professionals 其他专业人士Relatives 亲属Community friends 社区朋友Books 书籍Online resources 线上资源Other
Please share what you have found helpful or not helpful from any of your selections above. 以上选项，您认为哪些有帮助哪些没有帮助？
How has your child responded to professional assistance with mental health issues? 您孩子对出现精神健康问题时寻求专业帮助持什么态度？*

Actively cooperate 积极配合Did once but refused to continue 只求助过一次但拒绝继续Doesn’t want to seek any professional help 不想接受任何专业帮助I don't know 不清楚
Your child's current attitude towards medication? 您孩子目前对药物治疗持什么态度？*

Doctor didn’t subscribe 医生未开处方Child followed the prescription(s) 孩子接受医嘱Child refused to take medication 孩子拒绝服药Child had serious side effect(s) and had to stop 孩子对药物严重过敏并不得不中止服药Other
For "Other", please specify 若选“其他”，请具体说明：:
If you or your child has pursued any treatment or preventive measures, what have they been? 若您和孩子接受治疗或预防干预，具体措施是什么？

Medication 药物Individual counseling 咨询疗法Peer support program 同伴支持小组Other 其他
For "Other", please specify 若选“其他”，请具体说明：
Has your child's mental health been negatively impacted by COVID-19 (lockdown measures, social distancing, etc.)? 您孩子的心理健康是否因为新冠疫情而受到负面影响？

Yes 是的No 不是I'm not sure 不清楚
Do you think you need psychological guidance or treatment because of your child's illness? 您是否因为孩子的心理健康问题而考虑需要接受心理指导或治疗？*

No need 不需要Already seeking professional guidance for myself 已经在为自己寻求专业的心理指导帮助Will need professional guidance for myself 考虑需要为自己寻求专业的心理指导帮助Need parent peer support 需要其他家长同伴的支持
If you have never received or participated in any mental health treatment or preventative measures yourself, what have been reasons for you to not do so? 若您从未接受或参与过任何精神健康疗法或自我预防评估，是什么原因阻止您？*

Not interested or don't find it necessary 不感兴趣或不需要Don't know how 不知道如何寻求帮助Language barrier 语言障碍Lack of available resources 资源缺乏Financial barriers 经济有限Concern about stigma 担心被“污名化”Have no time (too busy) 没有时间（太忙）Other
For "Other", please specify. 若选“其他”，请具体说明：
If we run a parent peer-support program, what would you like to get from the program? (Please select all that you would be interested in.) 若我们成立一个父母支持小组，您希望从中收获什么？（可多选项）*

A safe space to share knowledge and experiences of youth mental health一个安全可信赖的环境可以分享青少年心理健康方面的知识和经验Emotional support from the group 从小组获得情感支持Guidance/mentorship from facilitators/group leaders 从小组领袖中得到指导Parenting and communication skills for effective dialog with your child/children 学到和孩子有效沟通的技巧Opportunities to learn how to build resilience有机会学到抗压能力Basics of Mental Health First Aid 精神健康急救知识Opportunities to learn from other parents about how to deal with a child’s mental health issues 向其他父母学习如何应对孩子心理健康问题Knowledge about mental health services and treatments 心理健康的治疗和服务知识Increased awareness about youth mental health 提高对青少年心理健康的防患意识Other
If "Other", please specify 若选“其他”，请具体说明：:
If you join the parent-support group, how would you like to help your peers? (Please select all that is applicable.) 若您加入父母支持小组，您会如何帮助他人？（可多选项）*

Share my experiences 分享自己的经验Share my knowledge and resources 分享自己的知识和资源Provide emotional support 提供情绪疏导支持Other
For "Other", please specify 若选“其他”，请具体说明：:
If you were to participate in a parent peer support group, what size would you prefer? 若您加入父母支持小组，您觉得小组合适的人数是多少？*

3 - 5 people 3-5人6 - 10 people 6-10人11 - 15 people 11-15人>15 people 多于15人
How often would you like to meet with the group? 您觉得多长时间聚会一次合适？*

Once a week 一周一次Every other week 两周一次Once a month 一月一次Every other month 两月一次
How long would you like the group to meet? 您觉得小组聚会该坚持多长时间？*

4 - 6 weeks 4-6周7 - 12 weeks 7-12周6 months 6个月1 year 1年>1 year 一年以上
What topics would you like to discuss? (please select all applicable) 您想讨论哪方面话题？（可多选项）*

Parent-child communication 亲子交流Basic information about all mental health disorders (symptoms & diagnoses) 精神疾患的基础知识（症状和诊断）Basic information about treatment options for mental health issues 心理健康问题和治疗方案的基础知识Deeper dive: Depression and anxiety 深入探讨：抑郁症和焦虑症Deeper dive: ADHD and ADD 深入探讨：多动症Deeper dive: Psychosis 深入探讨：精神疾患Deeper dive: Substance use disorders 深入探讨：药物滥用Personal development and resilience 个人发展和抗压力Cultural identity and heritage 文化认同和传承Racism and mental health 种族歧视和精神健康Social/community resources 社会/社区资源Peer support 同伴支持Suicide prevention 自杀干预Other
For "Other", please specify 若选“其他”，请具体说明：:
Has the pandemic and/or racism increased your level of stress and anxiety? 疫情和种族歧视对您是否造成更大压力和焦虑吗？*

Yes 是的No 不是
Has the pandemic and/or racism increased your child’s level of stress and anxiety? 疫情和种族歧视对您孩子是否造成更大压力和焦虑吗？*

Yes 是的No 不是I don't know 不清楚
How have your and your child's mental health been impacted by COVID-19 (lockdown measures, social distancing, loss of loved ones, etc)? 新冠疫情对您和孩子的心理健康造成影响吗？（封城措施、社交距离、丧失亲人等）
Parent-Child Communications 亲子沟通调查
How much time do you spend per week in meaningful conversation with your parent(s)/child(ren)? A meaningful conversation is one that has a purpose and also affords the participants the freedom to express themselves. 每周花多长时间进行有效亲子对话？有效沟通指自由表达和目标性交流。

0 - 1 hours 0-1小时每周2 - 3 hours a week 2-3小时每周4 - 5 hours a week 4-5小时每周6+ hours a week 6个小时以上每周
Which of the following activities do you share with your children? 您和孩子一起参与以下活动吗？

Walks 步行Sports 运动Video Games 电子游戏Movies/TV 电影/电视Mealtime conversations 餐间交流Other
If other, please specify, 若选“其他”，请具体说明：
How is your relationship with your child? (range from 1-10, 10 is having the closest relationship) 您和孩子的关系如何？（1-10的范围，10为最亲密的关系）

1

2

3

4

5

6

7

8

9

10

1 is Distant, 10 is Close
Is your child willing to share his/her thoughts with you? (range from 1-10, 10 is very willing to share) 您孩子愿意和您分享自己的想法吗？（1-10的范围，10为最愿意分享）

1

2

3

4

5

6

7

8

9

10

1 is Not willing, 10 is Very willing
Does the child have any friends? Do you know their friends? 您孩子有朋友吗？您了解他/她的朋友吗？
Aside from their academic studies, what topics do you talk about with your children? 除了学业，您和孩子还谈论什么话题？
Do you often encourage your child? Do you often hug them and say, "I love you"? 您常鼓励孩子吗？您常拥抱并表达对孩子的爱意吗？

1

2

3

4

5

6

7

8

9

10

1 is Not very often, 10 is Multiple times a day
Thank you for your response! 感谢您参与我们的调查

欢迎关注我们WAVES的心理健康服务！
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UCA Mental Health Community Needs Survey 华裔社区健康支持需求家长调查表

Demographic Information 个人基础信息

Needs for Mental Health Support 心理健康支持需求调查

Parent-Child Communications 亲子沟通调查

Thank you for your response! 感谢您参与我们的调查