Thinking aboutall ofyour visits with adolescents age 10-21 yrs, indicate how frequently you do the following.
Always / Usually / Sometimes / Never
1)Use a standardized tool to assess risky behaviors (e.g., sexual activity, substance use, safety). /  /  /  / 
2)Counsel them about risky behaviors. /  /  /  / 
3)Ask about both physical and mental health concerns. /  /  /  / 
4)Talk privately, without a parent in the room. /  /  /  / 
My adolescent patients… / Definitely Yes / Mostly Yes / Mostly No / Definitely No
5)…will tell metheir concerns, even if I don’t ask. /  /  /  / 
6)…know what services they can get without parentalconsent. /  /  /  / 
7)…are honest when talking to me about their health, personal life, and activities. /  /  /  / 
8) …feel that my clinic site is welcoming to teens. /  /  /  / 
Indicate your level of agreement with the following. / Strongly Agree / Agree / Disagree / Strongly Disagree
10)I am comfortable caring for all types of adolescent patients. /  /  /  / 
11)I am confident in my ability to counsel adolescent patients on behavior change. /  /  /  / 
12)I am confident in my ability to recognize mental/behavioral health issues in my adolescent patients. /  /  /  / 
13)I am confident in my ability to connect my adolescent patients with resources to meet their health needs. /  /  /  / 
14)I have sufficient options to connect my adolescent patients with mental/behavioral health providers. /  /  /  / 

15) What are your barriers to providing comprehensive care for adolescents age 10-21 yrs?

______

16)What is your practice setting?

Primary care clinicCommunity health center / health department

School-based health centerOther ______

17)Please give your: Age: ______yrs Gender: ______Yrs at this site: ______

Thank you for completing this survey!