1. The consultant responded to my referral in a timely manner. 4

2. The consultants role was clearly explained to me. N

3. I felt I had a good relationship with the consultant. 4

4. I believe the consultation service was helpful. 3

5. I felt listened to by the consultant. 4

6. The consultant respected my opinions. 4

7. The consultant answered my questions. 4

8. I learned new ways to help children with challenging behaviors. N

9. The consultation service positively affected the way I relate to children. 4

10. Overall, I am satisfied with the consultation service I recieved. 4

11. I feel the referring situation has improved. 4

12. What is ONE thing youre doing differently because of the consultation service you received?

13. Would you recommend this consultation service to other childcare providers? Why or why not?

14. How can this consultation service be improved?

15. To be answered by the family: Over the past 30 days, how many days of work or school has the family/caregiver missed due to the challenges a child has experienced while in child care?

16. To be answered by the family: Please rate your stress level related to your child’s challenges at ChildCare(please edit if you like the idea of adding it):

Other comments:

OPTIONAL - Consultants Name:

OPTIONAL - Your Name: