Youth (required)

County (required)

County Worker (required)

C.C.R. Program (required)

C.C.R. Home (required)

Clinical Case Manager (required)

I. Please rate your satisfaction with the overall functioning of C.C.R./C.C.P as an agency by answering the following.

1.Please rate your ongoing communication with our agency in terms of responsiveness, professionalism, and courtesy.
1 2 3 4 5 excellent NA

2.Please rate the effectiveness of our discharge summary and the timliness of the report.
1 2 3 4 5 excellent NA

3.C.C.R./C.C.P. believes in the model of Partnership in Planning. Did you receive adequate assistance from all of our
3.staff in terms of discharge planning? Where we Partners in Planning with you?
1 2 3 4 5 excellent NA

4.Were your personal expectations of C.C.R./C.C.P fulfilled in terms of the effectiveness and usefulness of treatment
3.foster care/mental health services?
1 2 3 4 5 excellent NA

5.How could our agency have better met the needs of you and your client?

II.Case Management and Wraparound Services. Please rate satisfaction with the case management and wraparound
2.services that were provided by C.C.R./C.C.P and/or community resources by answering the following.

1.Were you satisfied with C.C.R./C.C.P case management services?
1 2 3 4 5 excellent NA

2.Were you satisfied with the psychiatric, psychological and/or therapeutic services that were either directly provided
2.by the clinical specialist or coordinated for the youth?
1 2 3 4 5 excellent NA

3.Did your receive adequate, timely and substantive documentation/reports, treatment plans, monthly summaries
4.and a discharge summary?
1 2 3 4 5 excellent NA

4.How could C.C.R./C.C.P case management services have been more effective and/or efficient?

III.Foster Parent Resources. Please rate the overall quality of the foster parents by answering the following.

1.Were the foster parents respectful and responsive to you and your client?
1 2 3 4 5 excellent NA

2.Were the foster parents responsive to the treatment needs and goals of your client and the biological family?
1 2 3 4 5 excellent NA

3.Did the foster parents provide a safe, comfortable, and healthy home environment for your client?
1 2 3 4 5 excellent NA

4.Did the foster parents provide for your client's physical and mental health needs (sought out community resources
4.and facilitated appointments)?
1 2 3 4 5 excellent NA

5.How could the foster parents have been more successful with this youth?

IV.Youth Success/Outcome Measures. Please rate your satisfaction with the outcome of this placement and any
2.changes in your client by answering the following.

1.Has your youth improved functioning in the following areas:

	no improvement				significant improvement
School	1	2	3	4	5	NA
Community	1	2	3	4	5	NA
Biological Family Interaction	1	2	3	4	5	NA
Peer Group	1	2	3	4	5	NA
Personal Life Satisfaction	1	2	3	4	5	NA
Mental Health	1	2	3	4	5	NA
Independent Living Skills	1	2	3	4	5	NA
Law Enforcement	1	2	3	4	5	NA
AODA Issues	1	2	3	4	5	NA
Sexualized Behavior	1	2	3	4	5	NA
Physical Aggression	1	2	3	4	5	NA

2.How would you assess the global functioning of this youth comparing the beginning of placement to the end of placement?
1 2 3 4 5 excellent NA

3.Based upon your determination and analysis of the achievement of target treatment goals as specified in the
3.Treatment Plan, was this a successful placement?
1 2 3 4 5 excellent NA

4.Please provide an overall satisfaction rating of this specific placement experience.
1 2 3 4 5 excellent NA

5.How could we have done a better job with this youth?