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Dually Involved Youth
Caregiver Services Survey
∞Inspire Hope-Seek Change-Strengthen Families∞
*
1.
Caregiver Name
(Required.)
Name
*
2.
Youth Name
(Required.)
Name
*
3.
Youth's Date of Birth
(Required.)
MM/DD/YYYY
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
4.
Today's Date
MM/DD/YYYY
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
This survey allows you to tell us what you think about your Dually Involved Youth experience. By completing this survey, you will help us improve the Dually Involved Youth initiative. Under each question check the answer that best matches what you feel about this experience. Most of the questions allow you to add additional comments if you wish. Your answers will remain confidential and will not help or hurt your relationship with the Court or with Job & Family Services.
5.
Are you satisfied with the types of services in your child's DIY treatment plan? (check one)
Very Satisfied
Mostly Satisfied
Not Sure
Mostly Dissatisfied
Very Dissatisfied
Why do you feel this way?
6.
Are there services you think your child should have gotten but did not? (check one)
Yes
No
Please explain.
7.
Are there services your child received you do not think they needed? (check one)
Yes
No
Please explain.
8.
Are you satisfied with the providers who gave your child services? (check one)
Very Satisfied
Mostly Satisfied
Not Sure
Mostly Dissatisfied
Very Dissatisfied
Why do you feel this way?
9.
If you are not satisfied, did you inform your child's case worker? (check one)
Yes
No
Please explain why or why not.
10.
Was there a service provider you liked better than the others? (check one)
Yes
No
Please explain.
11.
Was there a service provider you liked less than the others? (check one)
Yes
No
Please explain.
12.
How satisfied were you with the court proceedings? (check one)
Very Satisfied
Mostly Satisfied
Not Sure
Mostly Dissatisfied
Very Dissatisfied
Why do you feel this way?
13.
Staff valued me as a person? (check one)
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Why do you feel this way?
14.
Staff were willing to work with me? (check one)
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Why do you feel this way?
15.
When decisions about my child’s treatment were made, I felt like I was a partner with staff and that they listened to what I wanted to accomplish. (check one)
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Why do you feel this way?
16.
When I interacted with staff, they were professional, polite, and respectful. (check one)
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Why do you feel this way?
17.
Is there anything else you want to tell us about your experience with the DIY program?
Thank you for completing the survey. Your thoughts will help us improve this initiative.
In partnership between:
Clark County Domestic Relations Court-Juvenile Section ~ Clark County Department of Job and Family Services