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

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

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

4. I believe the consultation service was helpful. N

5. I felt listened to by the consultant. N

6. The consultant respected my opinions. N

7. The consultant answered my questions. N

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

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

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

11. I feel the referring situation has improved. N

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

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

14. How can this consultation service be improved?
x

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:
x

OPTIONAL - Consultants Name:

OPTIONAL - Your Name: