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In Home Counseling
Substance Abuse Evaluations
Local Mental Health Resources
Substance Abuse Resources
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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.)?
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
More Than 2.5 Hours
Are you able to get in contact with the counselor when needed?
If they don't answer, do they return your phone calls?
Does the counselor include you in discussions about your youth's treatment plan, goals, progress, etc.?
Did you feel heard and understood by your counselor?
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?
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