Parent/Guardian Post-Program Survey

Parent/Guardian Post-Program Survey

Instructions: This survey is to be completed by the teen’s parent/guardian, NOT by the teen.
Intern / Teen Information
Date*

MonthDayYear
Date
Name of Intern/Teen*

First NameLast Name
Name of Parent/Guardian Completing This Survey*

First NameLast Name
Select the BRF experience that your teen participated in:*

InternshipSmall GroupSchool Based Small Group
Education / Psychosocial Information
Where does the teen attend school? *
What grade is the teen in?*
Describe your teens' level of academic achievement. What is the teen's GPA?*
Does your teen have an IEP?*

YesNo
Is your teen enrolled in a curriculum based on intellectual or emotional disability?*

YesNo
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 BRF program?*

YesNo
If so, please explain:
Is the teen involved with CPS/CASA caseworkers?*

YesNo
If yes, please list name, organization, and address:
Has your teen had any interaction with law enforcement since beginning the BRF program?*

YesNo
If yes, please explain:
Has the teen been a victim or perpetrator of emotional, physical, or sexual abuse since beginning the BRF program?*

YesNo
If yes, please explain:
Drug & Alcohol History
To your knowledge, does your teen currently use:*

TobaccoOpiates (i.e. Oxycontin, Heroin)Abuse prescription pillsAlcoholCocaineMethamphetamineMarijuanaHallucinogensOther
Please explain any checked items.
Other Information

On a scale of 1 to 5, how was your teen's experience in the BRF program?*

	1	2	3	4	5

1 is Worst, 5 is Best

If you felt your teen's experience was less than 5, please share what we could have done to improve his/her experience:
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?*

YesNo
Would you recommend the BRF experience to another parent?*

YesNo
Is there anything else you would like to tell us about your teen's experience with BRF?
Parent/Guardian Survey

This survey is to be completed by the parent or guardian only, NOT by the teen.

Please respond to each question or statement by marking one box per row. In the past 7 days...*

Rows	Never	Rarely	Sometimes	Often	Always
My child felt happy.
My child felt great.
My child felt cheerful.
My child felt joyful.

Please respond to each question or statement by marking one box per row. Thinking about your child's life... *

Rows	Not at all	A little bit	Somewhat	Quite a bit	Very much
My child is hopeful about his/her future.
My child can reach his/her goals in life.
My child thinks his/her life is filled with meaning.
My child thinks his/her life has purpose.

Please respond to each question or statement by marking one box per row. In the past 7 days... *

Rows	Never	Almost never	Sometimes	Often	Almost always
My child felt nervous.
My child felt scared.
My child felt worried.
My child felt like something awful might happen.
My child worried when he/she was at home.
My child got scared really easily.
My child worried about what could happen to him/her.
My child worried when he/she went to bed at night.

Should be Empty: