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. 4

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?
I was able to include more visuals and aides to the child in my program based on the recommendation from my consultant. These recommendations helped the child with transitions and participation throughout the day.

13. Would you recommend this consultation service to other childcare providers? Why or why not?
I would recommend this consultant to other childcare providers. Throughout our time together, she consistently displayed empathy and active listening. She showed that she was passionate and committed to our success as the child's teachers, as well as his success in the classroom. She made sure to hear our concerns and responded with thoughtful feedback. She made a continuous effort to check in with us and ask if there is anything we needed to feel supported. She aided in creating a positive and reassuring environment by letting us know that the work we were doing was appreciated and making a difference. All of her responses and visits happened in a timely manner, making her a very reliable person.

14. How can this consultation service be improved?
I believe that this service was exceptional.

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: