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Services at Home
FAMILY QUESTIONNAIRE
2007-2008 SCHOOL YEAR

Dear Family Members:
We believe families can provide valuable information about the quality of United Services’ programs. Our on-going program improvement process relies on input from parents/caregivers, staff and other stakeholders. Therefore we would ask that you complete the following questions concerning any programs or services utilized between August 2007 and May 2008.
  • Please complete one survey per family and return by May 19, 2008, using the attached self-addressed envelope
  • If you prefer, you may complete on-line at www.unitedsrvcs.org
  • The survey should take approximately 10 minutes to complete. Please look for the results of the survey to be posted on our website after June 15, 2008.
Should you wish to discuss any of these issues in person, please contact Phyllis Schneider (USWest – Dardenne Prairie) or Karen Stepson (US East – St. Peters) at 636.926-2700.

Thank you for your support in helping us help others!

Sincerely,
Karen Stepson
United Services East		 Phyllis Schneider
United Services West

  Contact Information (optional)
Name
Phone
Email
   
  Check all services your child receives from United Services Staff in your home.

(PT) Physical
Occupational (OT)
Speech (ST)
Vision (VI)
Developmental Therapy (DT) / Special Education
   
  Family Support
SIBSHOP
Early Childhood Parenting Made Fun
Resource/Referral/Consultation
Parent Library
   
  Age of Child(ren) Enrolled
  0-1 2-3 4-5
   
  Length of Time Enrolled
Less than Six Months
Six Months to One Year
One to Two Years
More than Two Years
   
  School District
 
  (if you selected "Other", please specify)
   
  For each statement select SA=Strongly Agree, A=Agree, U=Uncertain, D=Disagree, SD=Strongly Disagree, NA=Not Applicable
There are no barriers that prevent my child or my family from accessing programs or services.
Staff works with parents to establish and maintain regular, ongoing two-way communication.
Therapist is prompt and consistently meets established visit schedule.
Staff works as a team in partnership with families.
Staff is sensitive to the needs of the children and families.
The therapist(s) is knowledgeable and professional.
The therapist(s) provides helpful information on my child’s progress.
The therapist(s) communicates techniques and activities to be used with my child at home.
I am able to use ideas and activities shared by therapist(s) with my child at other times.
I see positive changes in my child as a result of therapy.
The program meets the individual needs of my child.
The therapist demonstrates respect for our home and values.
Family support services are easily accessible.
Family support services have reduced my family's stress.
   
  The program provides information on the following:
Philosophy
Policies and procedures
   
  Overall Opinion
My overall opinion of the quality of the programs: (on a scale of 1-5)
Please choose one: 5 being the highest and 1 being the lowest
   
  Comments:
 
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THANK YOU FOR YOUR TIME!
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