Parent/Guardian Post-Internship Survey
Instructions: This survey is to be completed by the teen’s parent/guardian, NOT by the teen.
Date
*
-
Month
-
Day
Year
Date
Name of Intern/Teen
*
First Name
Last Name
Name of Parent/Guardian Completing this survey
*
First Name
Last Name
Education & Psychosocial Information
Where does the teen attend school?
*
What grade is the teen in?
*
Describe the level of academic achievement. What is the teen's GPA?
*
Does the teen have an IEP, is he/she enrolled in a curriculum based on intellectual or emotional disability?
*
In the last 30 days, please estimate how many days of school your child has missed.
*
Has your child been suspended, had any detentions or other school behavior issues since beginning the internship with BRF? Please explain.
*
Is the teen involved with any CPS/CASA caseworkers? Please list the name, organization, and address.
*
Has had any interaction with law enforcement since beginning the internship with BRF? If yes, please explain.
*
Has the teen been a victim or perpetrator of emotional, physical or sexual abuse since beginning the internship with BRF?
*
Drug and Alcohol Use
To your knowledge, does your teen currently use:
*
Tobacco
Opiates: Oxycontin, Heroin
Abuse prescription pills
Alcohol
Cocaine
Methamphetamine
Marijuana
Hallucinogens
Other
Please explain any checked items (if other box was checked, please specify):
*
Other Information
On a scale of 1-5, how was your teen's experience in the BRF Program?
*
Describe your teen's experience in the BRF program in one word.
*
Did you see any improvement in your child's behavior and/or attitude while in the program?
*
Would you recommend the BRF experience to another parent?
*
Is there anything else you would like to tell us about your teen's experience with BRF?
*
PROMIS SF 4a- Positive Affect
My child felt happy
*
never
rarely
sometimes
usually
always
My child felt great
*
never
rarely
sometimes
usually
always
My child felt cheerful
*
never
rarely
sometimes
usually
always
My child felt joyful
*
never
rarely
sometimes
usually
always
PROMIS SF 4a- Meaning & Purpose
My child felt hopeful about his/her future
*
never
rarely
sometimes
usually
always
My child can reach his/her goals in life
*
never
rarely
sometimes
usually
always
My child thinks his/her life is filled with meaning
*
never
rarely
sometimes
usually
always
My child thinks his/her life has purpose
*
never
rarely
sometimes
usually
always
PROMIS SF 8a- Anxiety
My child felt nervous
*
never
rarely
sometimes
usually
always
My child felt scared
*
never
rarely
sometimes
usually
always
My child felt worried
*
never
rarely
sometimes
usually
always
My child felt like something awful might happen
*
never
rarely
sometimes
usually
always
My child felt worried when he/she was at home
*
never
rarely
sometimes
usually
always
My child got scared really easy
*
never
rarely
sometimes
usually
always
My child worried about what could happen to him/her
*
never
rarely
sometimes
usually
always
My child worried when he/she went to bed at night
*
never
rarely
sometimes
usually
always
Submit
Should be Empty: