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* 1. How has the relationship and behavior of the family been the past year ?

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* 2. Is this a return to services or your families first time with a private provider in the home?

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* 3. How often does your child or family experience negative behaviors?

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* 4. Are you connected to natural supports in the community? (i.e. camps, groups, activities, gym membership, positive influences such as time with coaches, mentors, or relatives)

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* 5. How long do you wish for your family to be in home-based service? (select the best answers)

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* 6. How much 1-on-1 time does the parents/ guardians spend with the child in service a day?

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* 7. Were you placed on a waiting list?

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