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Medication Survey
In what NJ county do you currently reside?
-- Select --
Atlantic County
Bergen County
Burlington County
Camden County
Cape May County
Cumberland County
Essex County
Gloucester County
Hudson County
Hunterdon County
Mercer County
Middlesex County
Monmouth County
Morris County
Ocean County
Passaic County
Salem County
Somerset County
Sussex County
Union County
Warren County
I do not live in NJ
What is the child’s sex?
Female
Male
What is your relationship to your child?
Biological Parent
Foster/Resource Parent
Adoptive Parent
Kinship Provider
Family Member
Other
What is your child's age?
0-4 years
5-10 years
11-14 years
15-17 years
18 years or older
What is your child's race/ethnicity?
African-American
Asian
Caucasian
Hispanic, Latino, or Spanish Origin
Native American
Native Hawaiian or Other Pacific Islander
Other
Please indicate which type of medical insurance your child has?
Private Insurance
Medicaid
None
Other
Please indicate your child's mental health diagnosis (you may indicate more than one):
Intellectual Disabilities
Communication Disorder
Autism Spectrum Disorder
Schizophrenia
Schizoaffective Disorder
Bipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder
Disruptive Mood Dysregulation Disorder
Major Depressive Disorder/Other Depressions
Dysthymia/ Persistent Depressive Disorder
Separation Anxiety Disorder
Generalized Anxiety Disorder
Social Anxiety Disorder
Obssessive Compulsive Disorder
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
Post-Traumatic Stress Disorder (PTSD)
Acute Stress Disorder
Adjustment Disorder
Oppositional Defiant Disorder (ODD)
Intermittent Explosive Disorder
Conduct Disorder
Attention-deficit/Hyperactivity Disorder (ADD/ADHD)
Substance Use Disorder
Unknown Diagnosis
Undiagnosed
No disability
Other
Please indicate which medication(s) your child is currently taking (you may select more
than one):
Alprazolam (Xanax)
Amitriptyline (Elavil)
Aripiprazole (Abilify)
Asenapine (Saphris)
Atomoxetine (Strattera)
Bupropion (Wellbutrin)
Buspirone (BuSpar)
Carbamazepine (Tegretol)
Chlorpromazine (Thorazine)
Clomipramine (Anafranil)
Clonazepam (Klonopin)
Eszopiclone (Lunesta)
Fluoxetine (Prozac)
Fluphenazine (Prolixin)
Fluvoxamine (Luvox)
Guanfacine (Tenex, Intuniv)
Haloperidol (Haldol)
Iloperidone (Fanapt)
Imipramine (Tofranil)
Lamotrigine (Lamictil)
Lithium (Lithium carbonate, Eskalith)
Lorazepam (Ativan)
Paroxetine (Paxil)
Phenelzine (Nardil)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Sertraline (Zoloft)
Thioridazine (Mellaril)
Thiothixene (Navane)
Tranylcypromine (Parnate)
Trazodone (Desyrel)
Trifluoperazine (Stelazine)
Clonidine (Kapvay, Catapres)
Clozapine (Clozaril)
Desvenlafaxine (Pristiq)
Dextroamphetamine (Dexedrine, Adderal, Vyanse, Procentra)
Diazepam (Valium)
Diphenhydramine (Benadryl)
Duloxetine (Cymbalta)
Escitalopram (Lexapro)
Lurasidon (Latuda)
Methylphenidate (Ritalin, Metadate, Concerta, Daytrana, Focalin)
Mirtazapine (Remeron)
Nefazodone (Serzone)
Nortriptyline (Pamelor)
Olanzapine (Zyprexa)
Oxcarbazepine (Trileptal)
Paliperidon (Invega)
Valproic Acid (Depakote, Depakene)
Venlafaxine (Effexor, Pristiq)
Zaleplon (Sonata)
Ziprasidone (Geodon)
Zolpidem (Ambien)
No Medication
Other
Who initially prescribed your child's medication?
Neurologist
Psychiatrist
Pediatrician
Psychologist
Psychiatric Nurse
Primary Care Physician
Not Applicable
Other
Who currently provides refill prescriptions for your child’s medication?
Neurologist
Psychiatrist
Pediatrician
Psychologist
Psychiatric Nurse
Primary Care Physician
Therapist
Social Worker
Counselor
Case Manager
Not Applicable
Other
My child currently is involved in and/or receives services from the following systems
(please indicate one or more):
Mental Health
Perform Care
Child Welfare DCP&P (DYFS)
Juvenile Justice
Unified Care Management Organization (UCM)
Care Management Organization (CMO)
Youth Case Management (YCM)
Mobile Response & Stabilization Services (MRSS)
Family Support Organization (FSO)
Private Mental Health Provider
Family Success Center
Social Services / Welfare / TANF
Special Education
Developmental Disabilities
Other
N/A
Do you feel that mental health resources (private and/or public) have been easily accessible for
your child? If not, what are some barriers to their care? Please describe in the space below.
What is your email?
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