Parents and Agency Evaluation Form

Parents and Agency Evaluation Form

Please take a few moments to complete this survey
Please select Program *

Long-Term Emergency Shelter Therapeutic Foster Care Community Bed After-Care
1. Are you satisfied with the access to the treatment planning process and the assistance that you have received from the staff in working with you and your child? *

Yes No
2. Are you satisfied that the program is doing an effective job in helping your child? *

Yes No
3. Are you satisfied with the level of communication you have with the staff concerning your child's treatment? *

Yes No
4. Do you feel the program is responsive to your child's needs and that it is making a sincere attempt to help correct your problems areas through behavioral rehabilitation services? *

Yes No
5. Does staff use manner and treat you and your child with respect? *

Yes No
6. Are you satisfied with the referral and application process? *

Yes No
7. Are you satisfied with the facility accepting youth as described in the agency's proposal? *

Yes No

Please select one options for the questions listed above. *

Needs Major Improvement

Needs Improvement

Satisfied

Very Satisfied

Excellent

Any comments, opinions, or suggestions concerning the staff or program would be appreciated.
Name

First Name Last Name
Relationship
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