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Please help our agency make services better by answering some questions about the services your child received OVER THE LAST 3 MONTHS. Your answers are confidential and will not influence the services you or your child receive. Please indicate if you Strongly Agree, Agree, Are Undecided, Disagree, Strongly Disagree or if the question is not applicable to your situation for each of the statements below.

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* 1. Today's Date:

Date

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* 2. Does your child currently receive School Based Services, In-Home Services or both?

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* 3. If your child receives In-Home services, please choose which county you live in:

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* 4. If your child receives School Based Services, please choose which school they attend:

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* 5. Collaboration

  Strongly Agree Agree Undecided Disagree Strongly Disagree N/A
I believe the goals on my child's treatment plan accurately reflect their strengths and challenges.

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* 6. Accessibility

  Strongly Agree Agree Undecided Disagree Strongly Disagree N/A
My family has struggled in the past to access mental health services for my child.
Having these services makes it easier for my child to access the mental health services they need.

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* 7. Communication

  Strongly Agree Agree Undecided Disagree Strongly Disagree N/A
Staff communicate with me in such a way that I understand my child's diagnosis, goals, treatment and progress.
Staff have adequately explained to me the services available to my family and child through the program, as well as other services Northern Pines offers.

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* 8. Outcomes

  Strongly Agree Agree Undecided Disagree Strongly Disagree N/A
I have seen my child make progress as a result of the interventions staff use and the relationships my child has with staff.

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* 9. Professionalism

  Strongly Agree Agree Undecided Disagree Strongly Disagree N/A
Staff treat my family and my child with respect.

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