1. The consultant responded to my referral in a timely manner. 3

2. The consultants role was clearly explained to me. 3

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

4. I believe the consultation service was helpful. 2

5. I felt listened to by the consultant.

6. The consultant respected my opinions. 2

7. The consultant answered my questions. 1

8. I learned new ways to help children with challenging behaviors. 2

9. The consultation service positively affected the way I relate to children. 2

10. Overall, I am satisfied with the consultation service I recieved. 2

11. I feel the referring situation has improved. 2

12. What is ONE thing youre doing differently because of the consultation service you received?
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13. Would you recommend this consultation service to other childcare providers? Why or why not?
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14. How can this consultation service be improved?
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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: