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Feedback
Your Name - First and Last
Youth Name - First and Last
Counselor Name - First and Last
Behavioral Assistant Name - First and Last (if no BA - leave blank)
Does the counselor have effective scheduling (showing up on time, keeping scheduled meetings, reaching out to confirm scheduled meetings, etc.)?
*
Yes
No
Please add any comments you would like to share about effective scheduling:
On average how long would your counselor stay in the home for?
*
Less Than 1 Hour
1 Hour
2 Hours
2.5 Hours
More Than 2.5 Hours
Are you able to get in contact with the counselor when needed?
*
Yes
No
If they don't answer, do they return your phone calls?
*
Yes
No
N/A
Does the counselor include you in discussions about your youth's treatment plan, goals, progress, etc.?
*
Yes
No
Did you feel heard and understood by your counselor?
*
Yes
No
If you do not feel heard by your counselor - please explain
What could make the services you have received from your counselor more helpful?
Overall, how would you rate your experience?
*
Poor
Fair
Good
Very Good
Excellent
Submit
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