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* 1. Youth's Name  (optional):

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* 2. Relationship of the person completing the form for the youth (include contact number if you would like a call back to discuss these responses further):

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* 3. Name of Behavioral Assistant (BA) or Clinician you are evaluating:

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* 4. I was contacted by the Clinician/BA within a week from the start of services to schedule the initial meeting.

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* 5. I was given a description of the services that were to be provided so that I had a full understanding of what the level of service entailed.

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* 6. I was involved in developing treatment goals for my child and felt the treatment goals were effectively addressed throughout services.

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* 7. The services were consistent throughout the course of treatment on the part of the Clinician/BA and in the case of tardiness or missed appointment, the Clinician/BA notified me and made the effort to reschedule the appointment.

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* 8. I felt that my child’s services were provided in a manner that was sensitive to my culture/cultural background.

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* 9. I felt services were helpful to my child and/or family.

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* 10. Please provide any additional feedback that you feel would be helpful for us to improve services.

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