1 Start 2 Complete Please select your answer: * Key: 1 = strongly disagree - 5 = strongly agree 12345 This session increased my knowledge or skills. This session increased my knowledge or skills. - 1 This session increased my knowledge or skills. - 2 This session increased my knowledge or skills. - 3 This session increased my knowledge or skills. - 4 This session increased my knowledge or skills. - 5 As a result of this webinar, my current practice has been: * Please leave comments below (optional) Confirmed Changed Need more information Please leave comments here. Please select your answer: * Key: 1 = strongly disagree - 5 = strongly agree 12345 As a result of this webinar, I will or can see ways to improve my practice. As a result of this webinar, I will or can see ways to improve my practice. - 1 As a result of this webinar, I will or can see ways to improve my practice. - 2 As a result of this webinar, I will or can see ways to improve my practice. - 3 As a result of this webinar, I will or can see ways to improve my practice. - 4 As a result of this webinar, I will or can see ways to improve my practice. - 5 If no, please explain: Please select your answer: * Key: 1 = poor - 5 = excellent 12345 Overall the quality of this educational activity was: Overall the quality of this educational activity was: - 1 Overall the quality of this educational activity was: - 2 Overall the quality of this educational activity was: - 3 Overall the quality of this educational activity was: - 4 Overall the quality of this educational activity was: - 5 Was there anything that was particularly helpful or enjoyable? If so please describe: Was there anything that was a problem or would have improved the educational activity? Please specify: What other topics or formats would you be interested in for future educational programs? Name (First and Last) * REACH TRAINED * Yes No Please select your discipline: * Pediatrics Developmental & Behavioral Peds Family Medicine General Psychiatry Child/Adolescent Psychiatry Nurse Nurse Practitioner Psychology Other... Please select your discipline: Other... Practice * Family Med Pediatrics Med-Peds Other... Practice Other... Please rate the following: * Key: 1 = very easy - 5 = very difficult 12345 How easy is it for you to link your patients with mental health providers (e.g. therapists) in your community? How easy is it for you to link your patients with mental health providers (e.g. therapists) in your community? - 1 How easy is it for you to link your patients with mental health providers (e.g. therapists) in your community? - 2 How easy is it for you to link your patients with mental health providers (e.g. therapists) in your community? - 3 How easy is it for you to link your patients with mental health providers (e.g. therapists) in your community? - 4 How easy is it for you to link your patients with mental health providers (e.g. therapists) in your community? - 5 How easy is it for you to link your patients with child psychiatrists in your community? How easy is it for you to link your patients with child psychiatrists in your community? - 1 How easy is it for you to link your patients with child psychiatrists in your community? - 2 How easy is it for you to link your patients with child psychiatrists in your community? - 3 How easy is it for you to link your patients with child psychiatrists in your community? - 4 How easy is it for you to link your patients with child psychiatrists in your community? - 5 What are the barriers you experience in trying to link your patients with mental health providers (e.g. therapists) in your community? * Key: 1 = not a barrier - 5 = significant barrier 12345 Out of pocket expense Out of pocket expense - 1 Out of pocket expense - 2 Out of pocket expense - 3 Out of pocket expense - 4 Out of pocket expense - 5 Insurance doesn't cover sufficient numbers of therapists Insurance doesn't cover sufficient numbers of therapists - 1 Insurance doesn't cover sufficient numbers of therapists - 2 Insurance doesn't cover sufficient numbers of therapists - 3 Insurance doesn't cover sufficient numbers of therapists - 4 Insurance doesn't cover sufficient numbers of therapists - 5 Lack of available providers Lack of available providers - 1 Lack of available providers - 2 Lack of available providers - 3 Lack of available providers - 4 Lack of available providers - 5 Insufficient quality or expertise of providers Insufficient quality or expertise of providers - 1 Insufficient quality or expertise of providers - 2 Insufficient quality or expertise of providers - 3 Insufficient quality or expertise of providers - 4 Insufficient quality or expertise of providers - 5 Are there other barriers? (Please specify) What are the barriers you experience in trying to link your patients with child psychiatrists in your community? * Key: 1 = not a barrier - 5 = significant barrier 12345 Out of pocket expense Out of pocket expense - 1 Out of pocket expense - 2 Out of pocket expense - 3 Out of pocket expense - 4 Out of pocket expense - 5 Insurance doesn't cover sufficient numbers of therapists Insurance doesn't cover sufficient numbers of therapists - 1 Insurance doesn't cover sufficient numbers of therapists - 2 Insurance doesn't cover sufficient numbers of therapists - 3 Insurance doesn't cover sufficient numbers of therapists - 4 Insurance doesn't cover sufficient numbers of therapists - 5 Lack of available providers Lack of available providers - 1 Lack of available providers - 2 Lack of available providers - 3 Lack of available providers - 4 Lack of available providers - 5 Insufficient quality or expertise of providers Insufficient quality or expertise of providers - 1 Insufficient quality or expertise of providers - 2 Insufficient quality or expertise of providers - 3 Insufficient quality or expertise of providers - 4 Insufficient quality or expertise of providers - 5 Are there other barriers? (Please specify) In an average week, how many patients (under 21) do you have a major role (e/g/ services such as evaluation, monitoring, med management, counseling, referral, involvement with schools, coordination of treatment) in provision of mental or behavioral health management? 0/week 1-5/week 6-10/week 11-20/week 21-30/week Other... In an average week, how many patients (under 21) do you have a major role (e/g/ services such as evaluation, monitoring, med management, counseling, referral, involvement with schools, coordination of treatment) in provision of mental or behavioral health management? Other... Leave this field blank
