Better Together Mesa
Youth Satisfaction Survey
Youth Name
*
First Name
Last Name
Location:
*
KJ House
Evaluation:
*
30 Day
60 Day
90 Day
Semi Annual
Other
Living at this facilty, I have,
*
Rows
Outstanding
Exceeds Expectations
Meets Expectations
Needs Improvement
Below Expectations
Significantly Below Expectations
All my needs met
Room to grow as an individual
A safe living environment
Enjoyed my living experience
Youth Questions
*
Rows
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
The house manager has provided me with clear explanation of what is expected of me while living at this facility
The house manager checks with me daily to answer any questions or concerns I may have
I have been provided the necessary living essentials (toothbrush/paste, deoderant, shampoo, conditioner, body wash, clean undergarments, access to laundry)
The living environment is calming and a good place to reflect
Please explain any and all concerns that you may have while living at this facility.
What goals have you set for yourself to improve the quality of living outside the home.
*
ie. kindness, cleanliness, self care, homework...etc...
In the next 6 months, my top two goals to achieve are:
*
ie. graduate high school, improve my grades, pass treatment..etc...
Additional comments/notes:
Youth Signature:
*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Print
Submit
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