Participant Survey

Dear Parent, Guardian, or Participant (if adult)

We want to know if the services being provided to you by Youth Advocate Programs are meeting the needs of the individual served. Please take a few minutes to answer the following questions. Your input is valuable to us, and we thank you for your time and thoughtful response. Please be sure to enter the reference code from your mailed letter in question number one.

*1.Please enter your online reference code (refer to upper right corner of mailed survey).(Required.)

2.Are you satisfied with your Treatment Plan / Individualized Service Plan?

Yes

N/A

Comment:

3.Is your Treatment Plan / Individualized Service Plan being followed?

Yes

N/A

Comment:

4. Are you involved with staff in working on goals and sharing information?

Yes

N/A

Comment:

5.Do you feel you are kept updated by your staff/worker?

Yes

N/A

Comment:

6.Are you satisfied that staff respect you and the participant?

Yes

N/A

Comment:

7.Have you been contacted by the local program in the past month, either in person or by phone?

Yes

N/A

Comment:

8.Are the number of hours recommended being provided?

Yes

N/A

Comment:

9.Do you feel that your privacy is being protected?

Yes

N/A

Comment:

10.Do you feel the services are being delivered professionally?

Yes

N/A

Comment:

11.What do you feel is the most helpful about the services being provided?

12.Are you satisfied that the services are making a difference in your child and/or family’s life, or your life if adult?

Yes

N/A

Comment:

13.Information on the person completing this survey

Phone Number

Name of Person Completing this Form

Relationship to Participant

Current Progress,

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