Satisfaction Survey

Dear Parent and/or Guardian, 

We want to know if Youth Advocate Programs' services are meeting the needs of each person and family we serve. Please take a few minutes to answer the following questions. Please be sure to enter the reference code from your mailed letter in question number one.

Thank you for your time and thoughtful reply!

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

Please answer question 1 before continuing.

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

1. Yes

1. No

1. N/A

Please answer question 2 before continuing.

1a.  Comment:

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

1. Yes

1. No

1. N/A

Please answer question 5 before continuing.

2a.  Comment:

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

1. Yes

1. No

1. N/A

Please answer question 7 before continuing.

3a.  Comment:

4.  Does the advocate/staff keep you updated?

1. Yes

1. No

1. N/A

Please answer question 8 before continuing.

4a.  Comment:

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

1. Yes

1. No

1. N/A

Please answer question 10 before continuing.

5a.  Comment:

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

1. Yes

1. No

1. N/A

Please answer question 13 before continuing.

6a.  Comment:

7.  Are the number of hours recommended being provided? 

1. Yes

1. No

1. N/A

Please answer question 15 before continuing.

7a.  Comment:

8.  If you are receiving teleservices, i.e. telemedicine/telehealth, do you feel that your privacy is being protected? 

1. Yes

1. No

1. N/A

8a.  Comment:

9.  If you are receiving teleservices, i.e. telemedicine/telehealth, do you feel that the services are being delivered in a professional manner?

1. Yes

1. No

1. N/A

9a.  Comment:

10.  What do you feel is the most helpful, if anything, about the services being provided?

11.  Are you satisfied that the services are making a difference in your child and family’s life?

1. Yes

1. No

1. N/A

Please answer question 18 before continuing.

11a.  Comment:

12.  Phone Number:

13.  Person Completing this Form and Relationship to Participant

Person Completing this Form

Relationship to Participant

Thank you for completing this survey!