Jewish Therapeutic Day School Needs Assessment Parent Survey

Jewish Therapeutic Day School Needs Assessment

Parent Survey
The following survey will help us to better understand the needs of the children in our community who are struggling with mental health concerns that affect their functioning in school. Please help us work toward addressing these needs by taking a few minutes to complete this survey.

Please note:
1. The term "therapeutic school" is commonly used in this survey. In this context, this term refers to a comprehensive treatment day school setting (not residential) in which mental health and behavioral issues that arise during the school day can be addressed successfully. This is accomplished through a highly intensive and collaborative therapeutic model which supports students emotionally and behaviorally while at the same time facilitates academic progress.
2. Your responses are completely confidential and will not be shared with any third parties.
3. This survey should not take more than 10 minutes to complete.
For more information, please contact Rabbi Dr. Yisrael Rothwachs at yrothwachs@sinaischools.org.
We recognize that you may be inclined to remain anonymous. We ask that you consider sharing your name and contact information so that if we have follow up questions, we can contact you. In either case, we thank you for your participation.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
City of Residence*
State of Residence*
How many children do you have that could potentially benefit from a therapeutic school?*
For approximately how long are you willing to allow your child(ren) to travel to school?*
With all else being equal, would you prefer a Jewish Therapeutic School to be housed within an existing Yeshiva Day School or to be a separate stand-alone school?*

Sex of child*
Current grade*
In which grade did your child’s struggles begin to interfere with their success in school?*
Has your child already been referred out of a Yeshiva Day School?*
If so, at what age*
Your child's current school placement*

Bergen County Yeshiva Day SchoolNon Bergen County Yeshiva Day SchoolTherapeutic Day SchoolResidential Therapeutic SchoolPublic SchoolHome SchoolOther
How long has your child been in his/her current school placement?*
Do you think that your child would benefit from enrolling in a Therapeutic Yeshiva Day School? *
Would you be interested in enrolling your child in a Therapeutic Yeshiva Day School?*
Has your child ever been admitted into an inpatient psychiatric placement?*
Has your child ever been admitted into an outpatient psychiatric placement?*

Please indicate the challenge(s) with which your child struggles and to what degree each challenge is impacting his/her functioning:*

	Not at All	Mildly	Moderately	Significantly	Very Significantly
Anxiety
Depression
Panic Attacks
Behavioral Disorder
Mood Disorder
Bipolar Disorder
Borderline Personality Disorder
Learning Disability
OCD
ADHD
ASD
Poor Peer Relationships and/or Social Skills Deficit
Schizophrenia/Psychosis
Eating Disorder
Substance Use or Abuse
Verbal Aggression
Violent behavior towards parents only
Violent behavior in and out of home
Self Harm
School Refusal
Executive Functioning Deficit
Impaired Academic Performance
Gender and/or sexual identity
Religious/spiritual struggles

Anxiety_parent_child1
Depression_parent_child1
Panic_Attacks_parent_child1
Behavioral_Disorder_parent_child1
Mood_Disorder_parent_child1
Bipolar_Disorder_parent_child1
Borderline_Personality_Disorder_parent_child1
Learning_Disability _Disorder_parent_child1
OCD_parent_child1
ADHD_parent_child1
ASD_parent_child1
Poor_Peer_Relationships_parent_child1
Schizophrenia_parent_child1
Eating_disorder_parent_child1
Substance_parent_child1
Violent_parents_parent_child1
Violent_home_out_parent_child1
School_refusal_parent_child1
0000Executive_functioning_parent_child1
Impaired_Academic_Performance_parent_child1
Gender_sex_identity_parent_child1
religious_spiritual_parent_child1
self_harm_parent_child1
verbal_aggression_parent_child1
How well is your child’s anxiety being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s depression being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s panic attacks being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s behavioral disorder being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s mood disorder being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s bipolar disorder being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s borderline personality disorder being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s learning disability being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s OCD being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s ADHD being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s ASD being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s poor peer relationships and/or social skills deficit being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s schizophrenia/psychosis being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s eating disorder being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s substance use or abuse being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s verbal aggression being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s violent behavior towards parents only being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s violent behavior in and out of home being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s self harm being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s school refusal being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s executive functioning deficit being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s impaired academic performance being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s gender and/or sexual identity being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s religious/spiritual struggles being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
From which of the following services could your child benefit?*

Psychiatric Care/MedicationCognitive Behavioral Therapy (CBT)Dialectical Behavioral Therapy (DBT)Group TherapyFamily TherapySocial Skills TrainingArt or Music TherapyNoneOther
Which services does your child currently receive?*

Psychiatric Care/MedicationCognitive Behavioral Therapy (CBT)Dialectical Behavioral Therapy (DBT)Group TherapyFamily TherapySocial Skills TrainingArt or Music TherapyNoneOther

Sex of child*
Current grade*
In which grade did your child’s struggles begin to interfere with their success in school?*
Has your child already been referred out of a Yeshiva Day School?*
If so, at what age*
Your child's current school placement*

Bergen County Yeshiva Day SchoolNon Bergen County Yeshiva Day SchoolTherapeutic Day SchoolResidential Therapeutic SchoolPublic SchoolHome SchoolOther
How long has your child been in his/her current school placement?*
Do you think that your child would benefit from enrolling in a Therapeutic Yeshiva Day School? *
Would you be interested in enrolling your child in a Therapeutic Yeshiva Day School?*
Has your child ever been admitted into an inpatient psychiatric placement?*
Has your child ever been admitted into an outpatient psychiatric placement?*

Please indicate the challenge(s) with which your child struggles and to what degree each challenge is impacting his/her functioning:*

	Not at All	Mildly	Moderately	Significantly	Very Significantly
Anxiety
Depression
Panic Attacks
Behavioral Disorder
Mood Disorder
Bipolar Disorder
Borderline Personality Disorder
Learning Disability
OCD
ADHD
ASD
Poor Peer Relationships and/or Social Skills Deficit
Schizophrenia/Psychosis
Eating Disorder
Substance Use or Abuse
Verbal Aggression
Violent behavior towards parents only
Violent behavior in and out of home
Self Harm
School Refusal
Executive Functioning Deficit
Impaired Academic Performance
Gender and/or sexual identity
Religious/spiritual struggles

Anxiety_parent_child2
Depression_parent_child2
Panic_Attacks_parent_child2
Behavioral_Disorder_parent_child2
Mood_Disorder_parent_child2
Bipolar_Disorder_parent_child2
Borderline_Personality_Disorder_parent_child2
Learning_Disability _Disorder_parent_child2
OCD_parent_child2
ADHD_parent_child2
ASD_parent_child2
Poor_Peer_Relationships_parent_child2
Schizophrenia_parent_child2
Eating_disorder_parent_child2
Substance_parent_child2
Violent_parents_parent_child2
Violent_home_out_parent_child2
School_refusal_parent_child2
Executive_functioning_parent_child2
Impaired_Academic_Performance_parent_child2
Gender_sex_identity_parent_child2
religious_spiritual_parent_child2
self_harm_parent_child2
verbal_aggression_parent_child2
How well is your child’s anxiety being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s depression being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s panic attacks being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s behavioral disorder being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s mood disorder being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s bipolar disorder being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s borderline personality disorder being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s learning disability being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s OCD being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s ADHD being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s ASD being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s poor peer relationships and/or social skills deficit being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s schizophrenia/psychosis being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s eating disorder being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s substance use or abuse being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s verbal aggression being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s violent behavior towards parents only being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s violent behavior in and out of home being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s self harm being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s school refusal being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s executive functioning deficit being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s impaired academic performance being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s gender and/or sexual identity being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s religious/spiritual struggles being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
From which of the following services could your child benefit?*

Psychiatric Care/MedicationCognitive Behavioral Therapy (CBT)Dialectical Behavioral Therapy (DBT)Group TherapyFamily TherapySocial Skills TrainingArt or Music TherapyNoneOther
Which services does your child currently receive?*

Psychiatric Care/MedicationCognitive Behavioral Therapy (CBT)Dialectical Behavioral Therapy (DBT)Group TherapyFamily TherapySocial Skills TrainingArt or Music TherapyNoneOther

Sex of child*
Current grade*
In which grade did your child’s struggles begin to interfere with their success in school?*
Has your child already been referred out of a Yeshiva Day School?*
If so, at what age*
Your child's current school placement*

Bergen County Yeshiva Day SchoolNon Bergen County Yeshiva Day SchoolTherapeutic Day SchoolResidential Therapeutic SchoolPublic SchoolHome SchoolOther
How long has your child been in his/her current school placement?*
Do you think that your child would benefit from enrolling in a Therapeutic Yeshiva Day School? *
Would you be interested in enrolling your child in a Therapeutic Yeshiva Day School?*
Has your child ever been admitted into an inpatient psychiatric placement?*
Has your child ever been admitted into an outpatient psychiatric placement?*

Please indicate the challenge(s) with which your child struggles and to what degree each challenge is impacting his/her functioning:*

	Not at All	Mildly	Moderately	Significantly	Very Significantly
Anxiety
Depression
Panic Attacks
Behavioral Disorder
Mood Disorder
Bipolar Disorder
Borderline Personality Disorder
Learning Disability
OCD
ADHD
ASD
Poor Peer Relationships and/or Social Skills Deficit
Schizophrenia/Psychosis
Eating Disorder
Substance Use or Abuse
Verbal Aggression
Violent behavior towards parents only
Violent behavior in and out of home
Self Harm
School Refusal
Executive Functioning Deficit
Impaired Academic Performance
Gender and/or sexual identity
Religious/spiritual struggles

Anxiety_parent_child3
Depression_parent_child3
Panic_Attacks_parent_child3
Behavioral_Disorder_parent_child3
Mood_Disorder_parent_child3
Bipolar_Disorder_parent_child3
Borderline_Personality_Disorder_parent_child3
Learning_Disability _Disorder_parent_child3
OCD_parent_child3
ADHD_parent_child3
ASD_parent_child3
Poor_Peer_Relationships_parent_child3
Schizophrenia_parent_child3
Eating_disorder_parent_child3
Substance_parent_child3
Violent_parents_parent_child3
Violent_home_out_parent_child3
School_refusal_parent_child3
Executive_functioning_parent_child3
Impaired_Academic_Performance_parent_child3
Gender_sex_identity_parent_child3
religious_spiritual_parent_child3
self_harm_parent_child3
verbal_aggression_parent_child3
How well is your child’s anxiety being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s depression being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s panic attacks being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s behavioral disorder being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s mood disorder being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s bipolar disorder being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s borderline personality disorder being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s learning disability being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s OCD being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s ADHD being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s ASD being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s poor peer relationships and/or social skills deficit being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s schizophrenia/psychosis being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s eating disorder being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s substance use or abuse being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s verbal aggression being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s violent behavior towards parents only being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s violent behavior in and out of home being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s self harm being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s school refusal being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s executive functioning deficit being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s impaired academic performance being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s gender and/or sexual identity being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
How well is your child’s religious/spiritual struggles being addressed?*

Not at AllSlightlyModeratelyVery WellExtremely Well
From which of the following services could your child benefit?*

Psychiatric Care/MedicationCognitive Behavioral Therapy (CBT)Dialectical Behavioral Therapy (DBT)Group TherapyFamily TherapySocial Skills TrainingArt or Music TherapyNoneOther
Which services does your child currently receive?*

Psychiatric Care/MedicationCognitive Behavioral Therapy (CBT)Dialectical Behavioral Therapy (DBT)Group TherapyFamily TherapySocial Skills TrainingArt or Music TherapyNoneOther

Additional Information

Please provide any additional information or concerns that you might have. For example, to what degree would stigma prevent you or your child from considering a placement in a Therapeutic Yeshiva Day School? What would you suggest be considered in order to minimize stigma? What factors are most important to you when considering educational and therapeutic options for your child?
Additional Information
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Jewish Therapeutic Day School Needs Assessment

Additional Information