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

2. The consultants role was clearly explained to me. 4

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

4. I believe the consultation service was helpful. 4

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.

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

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?
Yes , it is a good program

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? 0

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): 6

Other comments:

OPTIONAL - Consultants Name:

OPTIONAL - Your Name: