Respite Program Evaluation

Client Name(Required)

First Last

Respite Worker's Name(Required)

First Last

Date of Evaluation(Required)

Please take a moment to complete this short survey. It will help us know how we’re doing, and how we can better serve the needs of families in the future.

Thank you for taking this 4-minute survey. These questions are required by our funders in order to continue providing free, high-quality support. Your time and support is appreciated. Please note that we require your name to connect to your file in our system. We value your confidentiality and appreciate your open and honest feedback.

Please rate yourself on the following areas both BEFORE and AFTER the program.

BEFORE this Program(Required)

AFTER this Program(Required)

Please answer the following YES or NO questions

The most helpful part of this program or the respite worker was:(Required)

ei. Something your respite worker did for you/your family, the social connection etc.

Is there anything you would change about this program or the respite worker?(Required)

What was the most beneficial thing you did for yourself during the visits?(Required)

Is there anything else we should know?(Required)