Indiana United Methodist Children's Home
Needs Assessment Survey
Needs Assessment Survey
1. What service does your county most need for the children and families you serve which is least available?
2. Looking at the needs of the children you serve, please rate the programs listed below in terms of availability and importance.
AVAILABILITY
 1 - adequate availability
2 - limited availability
3 - no availability		 IMPORTANCE
 1 - very important
2 - somewhat important
3 - not important
1. 2. 3. Day Treatment 1. 2. 3.
1. 2. 3. Open Residential 1. 2. 3.
1. 2. 3. Staff Secure for Younger Males (ages 6 to 13) 1. 2. 3.
1. 2. 3. Staff Secure for Younger Females (ages 6 to 13) 1. 2. 3.
1. 2. 3. Staff Secure for Older Males (ages 13 to 17) 1. 2. 3.
1. 2. 3. Staff Secure for Older Females (ages 13 to 17) 1. 2. 3.
1. 2. 3. Home Based or Family Preservation Type Services 1. 2. 3.
1. 2. 3. Parenting Programs 1. 2. 3.
1. 2. 3. Shelter Care 1. 2. 3.
1. 2. 3. Respite Care 1. 2. 3.
3. When considering an out of home placement for children, please rate the following factors on a scale of 1 to 3
1 - primary consideration
2 - somewhat important
3 - not important
1. 2. 3. Cost
1. 2. 3. Location
1. 2. 3. Services Offered
1. 2. 3. Admission Process
1. 2. 3. Discharge/Aftercare Services
1. 2. 3. Services for Families
1. 2. 3. Transportation provided for Admission/Visitation
Thank you for completing the survey. To help us better provide services to emotionally disturbed youth and their families in your county, please provide the following information:
Name:
Title:
Agency Name:
City:
State:
Zip:
E-mail:
Phone:
Fax:
Thank you in advance for your time in completing this survey.

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